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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Transfusion related acute lung injury (TRALI)


Transfusion-related acute lung injury (TRALI) is a complication following transfusion of blood products and is potentially a life-threatening adverse event of transfusion. The first case of fatal pulmonary edema following transfusion was reported in the 1950s. In recent time, TRALI has developed from an almost unknown transfusion reaction to the most common cause of transfusion related major morbidities and fatalities. A clinical definition of TRALI was established in 2004, based on acute respiratory distress which has temporal association with transfusion of blood components. In 2008 a distinction between classic and delayed syndrome was proposed. However, pathophysiology of TRALI still remains controversial. A number of different models were proposed to explain the pathogenesis. The two, presently most accepted models, are not mutually exclusive. The first is the antibody mediated model and the second is the two-event model.

In this review article the definition of TRALI, patient predisposition, treatment, prevention and reporting guidelines are examined. The current knowledge on the topic TRALI is summarized.

Key words: transfusion, acute lung injury

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Preoperative management of hypoplastic left heart syndrome


Pediatricians are frequently involved in the care of cyanotic newborns in the labor and delivery room, as well as in the well baby nursery. Causes of hypoxia and cyanosis in the term newborn can be found within all physiological systems. Congenital heart structural diseases account for the largest diagnostic category. There have been significant advances during the past years in the diagnosis and treatment of neonates with critical congenital heart disease, especially in the field of pre- and post-operative intensive care.

The term hypoplastic left heart syndrome (HLHS) describes a spectrum of cardiac structural abnormalities characterized by marked hypoplasia of the left ventricle and ascending aorta. Prenatal diagnosis, initial resuscitation and optimal preoperative management are key elements that allow the best opportunity for low mortality and normal neurodevelopment in affected newborns.  Preoperatively, the goal is to achieve adequate systemic oxygen delivery. Patency of the ductus arteriosus (DA) is critical for survival until surgery. Blood flow to the pulmonary and systemic circulations should be nearly balanced (goal Qp/Qs ratio of 1).  The immediate therapy for all infants with HLHS is an intravenous infusion of prostaglandin E1 (PGE1) in order to manipulate the DA and maintain ductal patency. Oxygen saturations of 75% to 85% by pulse oximetry suggest an adequate balance between systemic and pulmonary blood flow.  Judicious use of inotropic support is initiated if evidence of low cardiac output is detected. Diuretics may be necessary to help alleviate the increased volume load on the right ventricle. The goal of respiratory management is to increase pulmonary vascular resistance and decrease systemic vascular resistance.  Infants with HLHS who are born with a severely restricted or no inter-atrial communication, a rare occurrence, have profound hypoxemia.  The severe restriction of blood flow across the atrial septum results in a life-threatening situation and these patients, which present with severe cyanosis and hemodynamic instability, require urgent postnatal cardiac catheterization to relieve the septal obstruction and improve oxygenation. Special attention should be paid to the prevention of brain injury and poor neurodevelopmental outcome.

Care for infants with HLHS is complex, and often multiple specialists are involved. Despite an increase in the number of newborns with complex congenital heart disease and a growing percentage of patients with single-ventricle physiology, it is possible to care for this particular group of patients and achieve acceptable mortality risks, even in centres with no pediatric cardiac surgery facilities, if good preoperative management protocols are followed.

Key words: congenital heart disease, newborn, intensive care, hemodynamics, PGE1, ductus arteriosus


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Diluted porcine surfactant lung lavages in children with severe ARDS


Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis.  Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation  of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) 200 for more than 12 hours.  Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment.

Keywords: ARDS, pulmonary surfactant, bronchoalveolar lavages, child


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Does inhalation injury increase the mortality rate in burn patients? Investigation of relationship between inhalation injury and severity of burn surface


Objective. Inhalation injury accounts for 20% to 80% of deaths in burn patients due to severe cardiopulmonary distress not seen in cutaneous injury alone.   However, there are few comparative studies or retrospective analyses of the injury severity or deaths of patients with inhalation injury.

Methods.  We evaluated 59 patients (31 with inhalation injury and 27 without inhalation injury) who had sustained a severe burn injury and were treated in the intensive care unit at our medical center from 2004 through 2006.   Of the 31 patients with inhalation injury, 14 (45.2%) died, and of the 27 without inhalation injury, 4 (16.7%) died.

Results.  We investigated specific aspects of the severity and mortality of burn patients.  The median (mean) burn index in patients without and with inhalation injury were 45 and 50 points (17.9 and 34.4), and the median (mean) prognostic burn index scores between patients with and without inhalation injury were 88.5 and 55.5 points (86.8 and 69.4). The median (mean) prognostic burn index scores in surviving patients with and without inhalation injury were 49.5 and 67 points (60.0 and 70.0), which suggest that patients with inhalation injury sustained significantly more severe cutaneous burns than did patients without inhalation injury.

Conclusions. We conclude that inhalation injury alone may be fatal, but many patients with inhalation injury also sustain more severe cutaneous burns, which can further increase the mortality rate.

Key words: inhalation injury, burn, burn index, mortality, prognostic burn index


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Comparison of remifentanil versus fentanyl general anesthesia for short outpatient urologic procedures


Study objectives. To compare the effect of remifentanil versus fentanyl isoflurane general anesthesia on Aldrete score, emergence, extubation and discharge times from the operating room (OR) and postanesthesia care unit (PACU) following short outpatient urologic procedures (panendoscopy and cystoscopy, bladder hydrodilatation, stent placement).

Patients and methods. 40 patients 18 years of age or older scheduled for short elective outpatient urological procedures with an expected duration of less than 30 minutes.

Following Institutional Review Board (IRB) approval and written informed consent, 40 American Society of Anesthesiologists (ASA) physical class 1-3 adult outpatients were enrolled and equally (n=20) randomized into remifentanil and fentanyl groups. Preoperatively, all subjects received intravenous (IV) midazolam 1-2 mg and were induced with propofol 2 mg/kg IV. Muscle relaxation was achieved with succinylcholine or rocuronium, followed by intubation. The remifentanil group received remifentanil 1 g/kg IV at induction with a maintenance dose of remifentanil 0.1 to 2 g/kg/min IV in the presence of 60% nitrous oxide (N2O)/40% oxygen (O2) and end-tidal isoflurane of 0.3 to 0.4% (for amnesia). The fentanyl group received fentanyl 2 g/kg IV at induction, maintenance dose of fentanyl 2 to 3 g/kg IV intermittent bolus, and 60% N2O/40% O2 with 2% end-tidal isoflurane. Muscle relaxation was reversed at the end of anesthesia as needed. Times for OR entry, emergence, extubation, total OR time (entry to exit) and PACU discharge time, as well as Aldrete scores at time of OR exit and PACU discharge were determined. Data was evaluated by ANOVA, t-test and Mann-Whitney tests. A p

Results. There was no significant difference between groups in age, gender, weight, ASA class, PACU analgesic or antiemetic use, or times of emergence, extubation, OR exit and PACU discharge. There was a significant difference (p<0.05) in OR exit Aldrete score but not PACU discharge Aldrete score. No adverse events were noted.

Conclusions. While there was no difference between the remifentanil and fentanyl groups regarding recovery time from OR and PACU, remifentanil patients had significantly better OR exit Aldrete scores with less sedation upon arrival at phase I PACU recovery than the fentanyl group. This anesthesia technique may prove helpful for fast-track eligibility of these patients.

Key words: remifentanil, fentanyl, isoflurane, general anesthesia, urologic procedures, outpatient surgery, Aldrete score, recovery time, discharge time


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