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Abstract Purpose Septic shock is a common threat, and is the primary cause of death in almost all critical care units. Mortality of septic shock remains exceedingly high. The early use of methylene blue (MB) in different doses as adjunctive to vasopressors has promising results. Methods This double-blind, randomized, controlled trial comprised 90 patients divided into 3 groups: Group A received a 100 ml 0.9% NaCl placebo over 20 min; Group B received an MB bolus of 1 mg/kg in 100 ml 0.9% NaCl, and Group C received MB bolus of 4 mg/kg in 100 ml 0.9% NaCl during the same period. Groups B and C were given a 0.25 mg/kg/hour infusion of MB for 72 h after the bolus dose. All patients were started on noradrenaline at an infusion rate of 0.1–0.2 µ/kg/min and were adjusted accordingly to maintain MAP ≥ 65 mmHg. Time of vasopressor discontinuation was the primary outcome while total doses of vasopressors, ventilation days, vasopressors free days, total ICU stay, total hospital stay, and mortality rate were the secondary outcomes. Results Groups B and C exhibited significantly decreased time to vasopressor termination, and vasopressor-free days at 28 days in comparison to Group A. However, there was no significant difference between Groups B and C. Groups B and C had significantly lower noradrenaline dosages compared to Group A, however, no significant difference between Group B and Group C was found. The difference between the three groups in mortality rate was near statistical significance (p = 0.083). Using the logistic regression model, the 4 mg/kg group was protective against mortality with a hazard ratio of 0.29 (95%CI: 0.09–0.90). Conclusion In cancer patients with septic shock, early adjunctive MB delivery reduces the time to a vasopressor stoppage and increases the vasopressor-free days. No significant difference between high and low MB bolus doses, and no significant adverse effects were noted. Compared to placebo, the 4 mg/kg bolus dose shows a survival advantage. Trial registration Prospectively registered at clinicaltrials.gov [NCT 06005558]. (Date of registration 15/08/2023).

Abstract. Introduction:. Postthoracotomy pain (PTP) is a severe pain complicating thoracic surgeries and its good management decreases the risk of PTP syndrome (PTPS). Objectives:. This randomized controlled study evaluated the efficacy of ultrasound-guided continuous erector spinae plane block (ESPB) with or without dexmedetomidine compared with thoracic epidural analgesia (TEA) in managing acute postoperative pain and the possible emergence of PTPS. Methods:. Ninety patients with chest malignancies planned for thoracotomy were randomly allocated into 3 equal groups. Group 1: TEA (20 mL of levobupivacaine 0.25% bolus, then 0.1 mL/kg/h of levobupivacaine 0.1%), group 2: ESPB (20 mL of levobupivacaine only 0.1% bolus every 6 hours), and group 3: ESPB (20 mL of levobupivacaine 0.25% and 0.5 μg/kg of dexmedetomidine Hcl bolus every 6 hours). Results:. Resting and dynamic visual analog scales were higher in group 2 compared with groups 1 and 3 at 6, 24, and 36 hours and at 8 and 12 weeks. Postthoracotomy pain syndrome incidence was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. The grading system for neuropathic pain score was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. Itching, pruritis, and urine retention were higher in group 1 than in ESPB groups. Conclusion:. Ultrasound-guided ESPB with dexmedetomidine is as potent as TEA in relieving acute PTP and reducing the possible emergence of chronic PTPS. However, the 2 techniques were superior to ESPB without dexmedetomidine. Erector spinae plane block has fewer side effects compared with TEA.

Background Overstay of inpatients is a big challenge to healthcare systems which interferes with the proper utilisation of the available resources and efficient delivery of care. Unnecessary days in the hospital may lead to patient complications including healthcare-associated infections, falls and delirium, which can negatively impact both patient and staff experience. This project aimed to reduce the cost of bed days of inpatient overstay through facilitating the discharge process using a multidisciplinary intervention approach.Methods The root causes of inpatient overstay were defined via a multidisciplinary approach. This project applied the extension Deming Cycle method: Find-Organise-Clarify-Understand-Study-Plan-Do-Check-Act (PDCA). Solutions to the root causes which led to process variation were implemented through three PDCA cycles conducted between January 2019 and July 2020.Results There was a significant reduction in the total number of overstay inpatients, the total number of overstay days, and the related bed costs in the first 3 quarters of 2019. A significant and sustained improvement in the emergency department average boarding time was attained in the first half of 2019 (reduced from 11.9 hours to 1.7 hours). A total estimated cost saving of SR30 000 000 (US$8 000 000) in terms of operational efficiency was achieved.Conclusion Early discharge planning and facilitating the patient discharge process significantly improves the average length of inpatient stay and patient outcomes and decreases hospital costs.

Introduction Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.Methods Prospective cohort study in 109 institutions in 41 countries. Inclusion criteria: children

Objectives Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs.Design A multicentre, international, collaborative cohort study.Setting 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020.Participants Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin’s lymphoma, Hodgkin lymphoma, Wilms’ tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer.Main outcome measure All-cause mortality at 30 days and 90 days.Results 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p

Recent progress in laboratory techniques, particularly, identification of novel disease-causing genes, has led to the detection of different gene mutations that might be implicated in the pathogenesis of different hematological disorders like pure red cell aplasia (PRCA) and neutropenia. An autoinflammatory disorder known as deficiency of adenosine deaminase 2 (DADA2) has been recently noticed to present with variable hematologic abnormalities. We report 2 patients who presented with hematologic abnormalities in which 2 ADA2 gene mutations were detected. The first case is a 5-year-old girl who presented with severe PRCA and autoimmune hemolytic anemia without any other manifestation of DADA2 that resulted from a novel CECR1 c.714_738dup, p. (Ala247Glnfs*16) homozygous variant. The second case is a 10-year-old boy, known to have Hodgkin lymphoma and was under follow-up for 6 years; he presented with persistent neutropenia and was discovered to be homozygous for ADA2 c.1447_1451del, p. (Ser483Profs*5). In conclusion, we report two different novels ADA2 variants in two children; the first presented with PRCA and the second presented with persistent neutropenia. This report aims to raise the concerns regarding the use of genetic testing in different hematologic diseases with indefinite etiology, as it will lead to the best therapeutic strategies without the need for unnecessary interventions.

INTRODUCTION: Sickle cell disease (SCD) is autosomal recessive disorder common in the Kingdom of Saudi Arabia (KSA). This is first study in KSA, and middle-east revealing characteristics of pediatric SCD patients admitted to pediatric intensive care unit (PICU). METHODS: Retrospective review of SCD patients admitted to PICU over 6-years-period (2013–2019). Data collected using patient's files and PICU book. Descriptive analysis and percentages presented in tabulated and graphical form. RESULTS: Fifty-eight patients admitted 93 times to PICU, (4.5% of total PICU admission). Most admissions were from station and emergency room (38, 33 admissions respectively). Admissions categorized into emergency and elective (59, 34 admissions respectively). Average length of stay was 1.9 days. Acute chest syndrome (ACS) (n = 28) represented 30% of admissions, followed by cerebrovascular accident (CVA) (18.2%). Five patients (5.37%) admitted for other neurological causes. Twenty-five (26.8%) admitted electively for stroke prevention, 9 (9.6%) admitted postoperatively. Considerable number of exchange transfusion in 65 (69.8%) admissions. Three needed inotropes, five invasive ventilation. Thirteen/58 (22.4%) had previous stroke, 20 (34.4%) had previous ACS, whereas significant number (n = 37, 63.8%) had frequent vaso-occlusive crisis. Mean white blood cell was 18.37 × 103/μl (emergency group), and 10.4 × 103/μl (elective group). Mean hemoglobin 7.8 g/dl and 9.67 g/dl in emergency and elective groups, respectively. Seventy percent of patients prescribed hydroxyurea and 27% of patients were on regular transfusion. Mortality rate of SCD in PICU was low (n = 2, 3.4%). CONCLUSION: PICU is one of the essential components of comprehensive health-care services for patients with SCD. Cooperation between intensivists, hematologists, and other health-care providers in addition to the early referral of critically ill SCD patients to PICU leads to better disease outcomes.

Abstract Background Posterior reversible encephalopathy syndrome is a neurotoxic condition that occurs as a result of the failure of posterior circulatory autoregulation in response to acute changes in blood pressure. Overperfusion with resultant disruption of the blood-brain barrier results in vasogenic edema, but not infarction. Posterior reversible encephalopathy syndrome can be the presenting feature of postinfectious glomerulonephritis, which has been reported in approximately 5% of hospitalized children, and it has been reported in very few cases of adult patients with sickle cell anemia. We report a very rare case of posterior reversible encephalopathy syndrome that occurred in a child with sickle cell anemia. This presentation should be differentiated from other neurologic manifestations that occur in patients with sickle cell anemia, because management is totally different. Case presentation We report what is to our knowledge the first reported case of a 9-year-old Saudi girl with sickle cell anemia who developed posterior reversible encephalopathy syndrome secondary to asymptomatic poststreptococcal glomerulonephritis. This occurred after full recovery from acute chest syndrome and severe vaso-occlusive crisis. Conclusions The purpose of this report is to emphasize that all efforts should be made to explore the causes of different neurologic manifestations that occur in patients with sickle cell anemia, because this will require different pathways of management.

Acquired platelet function defect might be a consequence of iron overload. Even though there are various complications of iron overload, only few reports have indicated some correlations with platelets dysfunction. We report a child with Diamond-Blackfan anemia who has significant complications from iron overload due to chronic blood transfusion, and one of these complications is acquired platelet function defect that manifests with frequent episodes of epistaxis. Therefore, we emphasize the necessity for further studies to confirm direct correlation between iron overload as a causative agent and platelets dysfunction. And we recommend screening for platelets function in patients receiving chronic blood transfusion aiming at possible prevention of any life-threatening bleeding.

We report a rare case of myelodysplastic syndrome that presented early as amegakaryocytic thrombocytopenia in a collodion baby, which is a rare congenital disorder characterized by thick, taut membrane resembling oiled parchment or collodion, which is subsequently shed. To our knowledge, this is the first reported case of a collodion baby who presented with amegakaryocytic thrombocytopenia and who has a significant family history of the same condition. We document the rarity of this possible association and also the need for further study to establish whether a causal relationship exists.

Purpose: Septic shock is a common threat, and is the primary cause of death in almost all critical care units. Mortality of septic shock remains exceedingly high. The early use of methylene blue (MB) in different doses as adjunctive to vasopressors has promising results. Methods: This double-blind, randomized, controlled trial comprised 90 patients divided into 3 groups: Group A received a 100 ml 0.9% NaCl placebo over 20 min; Group B received an MB bolus of 1 mg/kg in 100 ml 0.9% NaCl, and Group C received MB bolus of 4 mg/kg in 100 ml 0.9% NaCl during the same period. Groups B and C were given a 0.25 mg/kg/hour infusion of MB for 72 h after the bolus dose. All patients were started on noradrenaline at an infusion rate of 0.1–0.2 µ/kg/min and were adjusted accordingly to maintain MAP ≥ 65 mmHg. Time of vasopressor discontinuation was the primary outcome while total doses of vasopressors, ventilation days, vasopressors free days, total ICU stay, total hospital stay, and mortality rate were the secondary outcomes. Results: Groups B and C exhibited significantly decreased time to vasopressor termination, and vasopressor-free days at 28 days in comparison to Group A. However, there was no significant difference between Groups B and C. Groups B and C had significantly lower noradrenaline dosages compared to Group A, however, no significant difference between Group B and Group C was found. The difference between the three groups in mortality rate was near statistical significance (p = 0.083). Using the logistic regression model, the 4 mg/kg group was protective against mortality with a hazard ratio of 0.29 (95%CI: 0.09–0.90). Conclusion: In cancer patients with septic shock, early adjunctive MB delivery reduces the time to a vasopressor stoppage and increases the vasopressor-free days. No significant difference between high and low MB bolus doses, and no significant adverse effects were noted. Compared to placebo, the 4 mg/kg bolus dose shows a survival advantage. Trial registration: Prospectively registered at clinicaltrials.gov [NCT 06005558]. (Date of registration 15/08/2023). [ABSTRACT FROM AUTHOR]

Background: A significant postoperative pain has been documented in numerous breast cancer cases following modified radical mastectomy (MRM). We evaluated the effectiveness of dexmedetomidine (DEX) versus ketamine as adjuvants to local anaesthetic in erector spinae plane block (ESPB) in MRM. Methods: In this randomized controlled trial, 75 women with breast cancer scheduled for MRM were included. All patients underwent ESPB with 30 ml 0.25% bupivacaine and randomized into three equal groups: group A, ESPB group; group B: received 1 µg/kg DEX with the ESPB; and group C: given 0.5 mg/kg Ketamine with the block. Results: Compared with group A, VAS score at rest as well as movement were lower considerably in groups B and C (p < 0.05) at 6 h, 12 h, and 24 h. Group B had lower VAS scores at rest at 12 h and 24 h and during movement at 6 h, 12 h, and 24 h (p < 0.05) than group C. In comparison to A Group; B and C Groups required considerably less time to rescue analgesia and consumed significantly fewer total opioids (p < 0.05 and p < 0.001, respectively). In addition, total number of patients who required additional analgesia was markedly reduced in groups B and C compared to group A ;(p < 0.05). Conclusion: In MRM surgery, the postoperative opioids consumption and VAS values were lower in both groups DEX and ketamine as an adjuvant to bupivacaine which enhanced the analgesic profile and prolonged ESPB duration compared to ESPB alone, with DEX being superior to ketamine. [ABSTRACT FROM AUTHOR]

Background: It is critical to manage acute postoperative pain for patient satisfaction and better outcome. Erector spinae plane block (ESPB) can produce sensory blocking on both visceral and somatic levels. This study aimed to evaluate the ESPB efficacy in controlling acute postoperative pain in open nephrectomy for renal malignancies. Methods: This prospective randomized, controlled, open-label trial included 60 cases scheduled for open nephrectomy for renal malignancy under general anesthesia. Cases were assigned randomly into two equal groups. Group E administered continuous preoperative unilateral ESPB (20mL bupivacaine 0.25% bolus then 6 mL/h 0.1% for 48 hours). Group C administered intravenous (IV) patient-controlled analgesia (PCA) morphine (0.01 mg/kg/h). Postoperative analgesia was managed by morphine (3 mg IV in group E or 0.01 mg/kg bolus with a 15-min lockout in group C) to keep the visual analog scale (VAS) scores < 4. Results: Intraoperative fentanyl consumption and total morphine consumption in 1st 48 hours postoperatively were significantly lower in group E than group C (P= 0.001 and < 0.001, respectively). The time to first analgesic request was significantly longer in group E than group C (P < 0.001). VAS scores at movement and rest were significantly lower in group E than group C (P < 0.001). Conclusion: In renal malignancies, ESPB provided better analgesia with prolonged time and lower pain scores at both rest and movement compared to IV PCA following open nephrectomy. [ABSTRACT FROM AUTHOR]

Objective: The use of recombinant human growth hormone (rhGH) in difficult to wean patients with prolonged ventilation periods may increase the likelihood of weaning and thus reduce the mechanical ventilation time. This placebo-controlled randomized study aimed to assess the efficacy of rhGH on the weaning of prolonged mechanical ventilation. Study Design: The study was conducted in the National Cancer Institute, Cairo, Egypt, from March 2018 to August 2018. Enrolled patients (60) were randomized to the GH group and the control group, 30 in each group. Before randomization, the same management was offered to both groups. After randomization, in the GH group, patients received 4 IU rhGH IM, twice per day for ten days. In the control group, patients received placebo injections (saline) at the same intervals and conditions with the continuation of the regular ICU management given to both groups. The primary outcome measurement was the proportion of patients weaned in both groups. Results: There was no statistically significant difference (P > 0.05) between the two groups regarding their baseline data in terms of age, BMI, and gender. Ventilation days were significantly lower in the GH group than in the control group; 33.20 ± 16.57 vs. 48.73 ± 10.66 days (P < 0.001). The number of failed-to- wean patients was significantly lower in the GH group than the control group [10 (33.33%) vs. 22 (73.33%); (P = 0.002)]. The odds ratio (OR) was 0.18 (95% CI: 0.06-0.55), the Absolute Risk Reduction (ARR) was 0.4 (95% CI: 0.17-0.63) and the Number Needed to Treat (NNT) was 2.5 (95% CI: 1.58-5.93). In addition, the study showed no significant differences between the GH group and the control group concerning the blood pressure, blood sugar. During the study period, there was no statistically significant difference between groups as regards the incidence of ventilator-associated pneumonia (VAP) or the number of deaths. Conclusion: The use of rhGH in cases difficult-to-wean patient with prolonged ventilation period increases the likelihood of weaning and reduces the mechanical ventilation time [ABSTRACT FROM AUTHOR]

Objective: evaluate efficacy of combining multimodal analgesia and local anesthetic infiltration compared with caudal analgesia among pediatric patients undergoing major abdominal pediatric cancer surgery Methodology: This randomized controlled pilot study was carried out at postoperative care unit of our institution. This pilot study enrolled 90 children ASA I and II with cancer scheduled for major abdominal surgery through a midline incision. Intervention: patients were randomly divided into three equal groups. The morphine group received IV morphine at a dose of 0.1 mg/kg after induction of anesthesia. The caudal group underwent caudal block. The multimodal group received paracetamol, ketorolac and ketamine infusion, with local wound infiltration of levobupivacaine before skin incision and at the end of surgery. After surgery, all patients were maintained on PCA morphine postoperatively. Primary outcome measure was total postoperative morphine consumption. The secondary endpoints were VAS score for pain, the time to first PCA bolus, and the number of PCA doses. Results: that there were no between-group differences in the baseline characteristics of the participants. The three analgesic modalities provided adequate pain relief for up to 24 h. The multimodal and caudal groups did not significantly differ in terms of total morphine consumption (p = 0.521), time to first analgesic bolus (p = 0.136), or the number of total and active PCA boluses (p = 0.260 and p = 0.904, respectively). Both groups were superior to the morphine group regarding morphine consumption, time to first analgesic bolus, and the number of total and active PCA boluses Conclusion: Preemptive multimodal analgesia and caudal block offered comparable efficacy in the target population. [ABSTRACT FROM AUTHOR]

Background & objective: Intravenous fluid therapy is a critical step in the resuscitation of patients suffering from sepsis and septic shock. Meticulous hemodynamic monitoring is necessary before as well as during the fluid therapy to avoid under-as well as over-loading the patient. An evaluation of fluid status has been suggested to be done noninvasively using the inferior vena cava collapsibility index (IVC-CI). We assessed the effectiveness of IVC-CI in evaluating septic patients' responses to fluid therapy at our institution. Methodology: Forty cancer patients with spontaneous breathing, who met sepsis criteria and were admitted to the intensive care unit, were included in this cross-sectional study. Over the course of three hours, the patients received crystalloids intravenously at a rate of 30 ml/kg, while CVP, ultrasonography guided IVC-CI measurement, and the vital sign monitoring was done every 30 min. Patients were divided into a responder group and a non-responder group based on a 10% change in cardiac output (CO) one hour later. IVC-CI variations in the volume responsiveness prediction served as the main outcome measure. Results: According to the change in CO one hour after starting fluid treatment, 29 patients (72.5%) were classified as fluid responsive and the remaining 11 (27.5%) as fluid non-responsive. In the two groups, HR and IVC-CI decreased significantly; whereas MAP, CVP, and CO increased significantly. ROC-curve analysis showed a percent change ≥ 3.4% of IVC-CI predicted positive responsiveness with a sensitivity of 72.4% and a specificity of 63.6%. These values were 79.3% and 72.7%, respectively, for a change ≥ 6.3% after one hour. The baseline value of IVC-CI was not predictive of responsiveness. Conclusion: In cancer patients with sepsis or septic shock, the change in inferior vena cava collapsibility index during the first hour of fluid therapy can predict fluid responsiveness with a moderate degree of accuracy. [ABSTRACT FROM AUTHOR]

Background: Hyperthermic intraperitoneal chemotherapy (HIPEC), following cytoreductive surgery (CRS), is a lengthy procedure, usually associated with considerable bleeding due to the extensive nature of surgery. Various techniques have been used to decrease blood transfusion requirements., Objectives: This study aimed to evaluate the possible advantage of a single dose of tranexamic acid (TA) in such surgeries., Methods: In this randomized comparative pilot study, 60 patients scheduled to undergo CRS followed by HIPEC were randomly assigned to 2 equal groups: group 1 (TA group) that received 10 mg/kg of TA in 100 mL of 0.9% NaCl over 20 minutes after the induction of anesthesia and before surgical incision, and group 2 (control group) that received a placebo of 100 mL of 0.9% NaCl during the same time interval. The primary endpoint was the blood loss volume. The secondary endpoints were the number of patients requiring transfusion and the occurrence of any postoperative thrombotic events 30 days after surgery. Serum creatinine levels were measured before the operation and on postoperative days 1, 3, and 5. Intraoperative and first 24 hours urine outputs were also recorded. The levels of hemoglobin (Hb) were measured before the operation, immediately after the operation, and 5 days postoperatively., Results: Compared to the control group, the TA group exhibited lower intraoperative blood loss, as well as lower blood loss on postoperative day 1 and in total blood loss (P = 0.006, 0.035, and 0.001, respectively). However, the blood loss on the remaining postoperative days was comparable between both groups. Intraoperative blood transfusion requirements were lower in the TA group (P = 0.032) than in the control group. The total number of units of blood and plasma transfused was also lower in the TA group both intra and postoperatively (0.007, 0.40, and 0.032, 0.008, respectively) than in the control group. Hemoglobin levels, serum creatinine levels, and urine outputs during the first 24 hours postoperatively were comparable between the 2 groups. The thromboembolic events within 30 days were also comparable between the 2 groups., Conclusions: Administering a single dose of TA between the induction of anesthesia and the surgical incision may reduce blood loss and transfusion rates in CRS followed by HIPEC without causing significant adverse effects. It is a promising approach in surgeries where massive blood loss is expected shortly after anesthesia induction. This can minimize the drawbacks of repeated blood transfusions during and after the operation without causing significant adverse effects. Besides reducing the need for repeated blood transfusions, it would also reduce the costs of blood/blood products and the risks of transfusion., Competing Interests: The authors declare no conflict of interests., (Copyright © 2023, Ehab Hanafy et al.)