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Objectives: To summarize the evidence of the hemodynamic effects and vasopressor requirements of adult cardiac surgery patients with vasoplegic shock treated with hydroxocobalamin or methylene blue., Design: Systematic review and meta-analysis., Setting: Multi-institutional., Participants: Adult cardiac surgery patients with vasoplegic shock., Interventions: Administration of hydroxocobalamin or methylene blue., Measurements and Main Results: A total of 263 patients in four retrospective observational studies were included in a pooled analysis. There was no significant difference in the primary outcome, vasopressor requirement at 1 hour (mean difference [MD]: 0.00 mcg/kg/min norepinephrine equivalent [NEE], 95% confidence interval [CI]: -0.09 to 0.08). Hydroxocobalamin was associated with a significant improvement in mean arterial pressure at 1 hour (MD: 5.30 mmHg, 95% CI: 2.98 to 7.62), total vasopressor dose at 1 hour (MD: -0.13 mcg/kg/min NEE, 95% CI: -0.25 to -0.01), total vasopressor at 6 hours (MD: -0.15 mcg/kg/min NEE, 95% CI: -0.21 to -0.08). No differences were observed in systemic vascular resistance or mortality between groups. Three studies were deemed at moderate risk of bias and one at serious risk., Conclusions: Hydroxocobalamin has been shown to have a beneficial effect on hemodynamics and vasopressor requirements in vasoplegic cardiac surgery patients compared with methylene blue, although evidence is limited, and further well-powered randomized controlled trials are required., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Pruritus is a frequently reported and unpleasant side effect following intrathecal opioid use with frequency further increased among parturients. We have performed a systematic review to assess the overall efficacy of ondansetron for the prevention of pruritus in patients receiving intrathecal opioid as part of spinal anesthesia for cesarean delivery., Methods: A literature search of MEDLINE, Embase, Cochrane, and Web of Science databases was conducted from date of inception to September 2022. Studies that included patients undergoing cesarean delivery with spinal anesthesia using intrathecal opioid were included. The primary outcome was the presence of pruritus, and the secondary outcome was time to onset of pruritus. Data from included studies were pooled for analysis using an appropriately determined random-effects model. Outcomes were presented using forest plots and 95% confidence intervals. Additional sensitivity and subgroup analysis were performed. Trial sequential analysis was conducted for the primary outcome., Results: Twenty-three randomized controlled trials with a total of 2586 patients were included: 1219 received ondansetron, 1030 received a placebo, and a further 337 received a different study drug and were excluded from analysis. Opioids used in the included studies were morphine, fentanyl, and sufentanil. Patients who received ondansetron showed a significant reduction in the incidence of pruritus compared to the control group (RR, 0.81; 95% confidence interval [CI], 0.71-0.92; I 2 = 64%). There was no significant difference in pruritus onset between the groups (mean difference [MD], 17.54 minutes; 95% CI, -2.18 to 37.26; I 2 = 83%). The overall Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of quality of evidence was low., Conclusions: This systematic review has demonstrated a significant reduction in the incidence of pruritus following the use of ondansetron. This is in contrast to previously published meta-analyses. Studies included were of varying quality and some at high risk of bias with a high degree of statistical heterogeneity. Furthermore, high-quality and well-powered studies are required to confirm these findings., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 International Anesthesia Research Society.)

Introduction: Hypoxic-ischaemic brain injury (HIBI), is a common sequalae following out-of-hospital cardiac arrest (OOHCA), it is reported as the cause of death in 68% of patients who survive to ICU admission, while other patients can be left with permanent neurological disability. Prediction of neurological outcome follows a multimodal approach, including use of the biomarker, neurone specific enolase (NSE). There is however no definitive cut-off value for poor neurological outcome, and little research has analysed NSE and long-term outcomes in survivors. We investigated an NSE threshold for poor short-term neurological outcome and the relationship between NSE and poor neurological outcome in survivors., Methods: A retrospective study was conducted of all adult OOHCA patients admitted to the Royal County Sussex Hospital ICU between April 2017 and November 2018. NSE levels, Targeted Temperature Management (TTM), cross-sectional imaging, mortality and GCS on ICU discharge were recorded. Assessment of neurological function after a median of 19 months (range 14-32 months) post ICU discharge was undertaken following ICU discharge and related to NSE., Results: NSE levels were measured in 59 patients; of these 36 (61%) had a poor neurological outcome due to hypoxic ischaemic brain injury. Youden's index and ROC analysis established an NSE cut-off value of 64.5 μg/L, with AUC of 0.901, sensitivity of 77.8% and specificity of 100%. Follow-up of 26 survivors after 19 months did not show a significant relationship between NSE after OOHCA and long-term neurological outcome., Conclusion: Our results show that NSE >64.5 µg/L has a poor short-term neurological outcome with 100% specificity. Whilst limited by a low sample size, NSE in survivors showed no relationship with neurological outcome post OOHCA in the long term., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Intensive Care Society 2023.)

Aims: Although cryoballoon pulmonary vein isolation is a well-established treatment for paroxysmal atrial fibrillation (AF), it's role in persistent AF is unclear. We examined procedural success and long-term outcomes of cryoablation in persistent and longstanding persistent AF., Methods and Results: International multicentre registry from three UK and eight European centres. Consecutive patients undergoing cryoablation for persistent AF included. Procedural data, complications, and follow-up were prospectively recorded. Patients were followed-up at 3, 6, and 12 months with an electrocardiogram with open access to arrhythmia nurses thereafter. Ambulatory monitoring was dictated by symptoms. Success was defined as freedom from AF or atrial tachycardia lasting >30 s off antiarrhythmic drugs (AADs). Six hundred and nine consecutive cryoablation procedures. Mean procedure and fluoroscopy times were 95 ± 65 and 13 ± 10 min. Single procedure success rates were 368/602 (61%) off AADs over a median of 2.4 (1.0-4.0) years. Arrhythmia-free survival off AADs was 64% and 57% for persistent and longstanding persistent AF at 24 months of follow-up (P = 0.02). Rate of repeat ablations was 20% in persistent and 32% in longstanding persistent AF (P = 0.006). Cox regression analyses showed a significant association between duration of AF and left atrial diameter and arrhythmia recurrence [hazard ratio (HR) 1.05, P-value 0.01 and HR 1.02, P-value 0.004]., Conclusion: Cryoablation for persistent AF is safe, fast and has good outcomes at long-term follow-up. Cryoablation is reasonable as a first line option for these patients. Short procedure times may help increase capacity of cardiac units to meet the rising demand for AF ablation. Randomised control trials are needed to compare outcomes with different techniques., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)