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Disseminated Intravascular Coagulation (DIC) is a critical condition resulting from an imbalance between coagulation (blood clot formation) and fibrinolysis (clot breakdown). This complex disruption can lead to severe bleeding, thrombosis, and organ failure, making it essential to diagnose and manage DIC effectively across clinical settings such as sepsis, trauma, and obstetrics. What is DIC and how does it occur? DIC occurs when an abnormal activation of coagulation pathways leads to widespread microthrombi (small blood clots) throughout the body, ultimately exhausting clotting factors and leading to severe bleeding. Pathophysiology: The condition arises from various triggers, such as sepsis or trauma, causing the coagulation cascade to activate excessively. Outcome: The abnormal clotting blocks blood flow to organs, leading to tissue damage, while the simultaneous depletion of clotting resources heightens bleeding risk. Key components of hemostasis and fibrinolysis Hemostasis involves coagulation processes essential to stop bleeding and protect against infection. Fibrinolysis maintains vascular integrity by breaking down clots, preventing excessive clot formation. In DIC, the balance is disturbed, leading to either a pro-coagulant or fibrinolytic dominant state, both of which have significant clinical implications. Clinical contexts and mechanisms leading to DIC Sepsis Sepsis-induced DIC is common, affecting up to 50% of septic patients, doubling mortality risk. Mechanisms include tissue factor activation, impaired anticoagulant pathways, and diminished fibrinolysis. Microorganisms and host inflammatory responses (e.g., cytokine release) amplify coagulation, creating microvascular obstructions that can cause multi-organ failure. Trauma Trauma patients often exhibit DIC due to systemic inflammatory responses and tissue injury. Hypercoagulability may follow an initial bleeding phase, evolving into DIC. Management often involves hemostatic resuscitation strategies, with whole-blood resuscitation and tranexamic acid (TXA) as key interventions. Obstetrics Pregnancy-related hemostatic adaptations increase coagulation potential, posing DIC risk in obstetric emergencies like placental abruption or amniotic fluid embolism. Diagnosis is challenging due to normal pregnancy changes […]
December 24, 2024
With the increasing prevalence of end-stage renal disease (ESRD), patients often require repeated upper arm arteriovenous (AV) access procedures for hemodialysis. Effective anesthesia techniques are essential for these surgeries, as they must cover specific areas of the upper arm and axilla while minimizing discomfort and improving patient outcomes. The intercostobrachial nerve (ICBN) block, commonly paired with a supraclavicular brachial plexus block, is one approach that helps anesthetize the medial upper arm and axilla. However, the effectiveness of this block can vary depending on the approach. A recent study compared two ultrasound-guided approaches—proximal and distal ICBN blocks—to determine their efficacy in achieving a successful sensory block. Study objective and methods The study aimed to evaluate the effectiveness of proximal versus distal ICBN block approaches in providing adequate anesthesia during upper arm AV access surgeries. This randomized controlled trial included 60 ESRD patients who were randomly assigned to receive either a proximal or distal ICBN block, both administered as adjuncts to a supraclavicular brachial plexus block. Patients and outcome assessors were blinded to the block type to ensure objectivity. The anesthetic mixture for each block was 10 mL of a solution containing 0.25% levobupivacaine, 1% lidocaine, and 2.5 µg/mL epinephrine. Proximal ICBN block: This approach was applied near the second rib on the chest wall, targeting the point where the ICBN branches from the lateral cutaneous nerve. Distal ICBN block: This approach was delivered on the medial side of the upper arm, approximately 3-4 cm below the axilla. The primary outcome was achieving a successful sensory block in both the medial upper arm and axilla. Secondary outcomes included block performance, complications, and the need for additional anesthesia. Key findings Sensory block: The proximal approach achieved significantly higher sensory block in the axilla, with a success rate of 96.7% compared to 73.3% in […]
December 19, 2024
A recent study published in the British Journal of Anaesthesia by Maurice-Szamburski et al. examines the limitations of traditional pain assessment methods in predicting chronic postsurgical pain (CPSP). The researchers propose a shift in focus from pain intensity to patient-reported pain experience, identifying this as a more reliable predictor of long-term pain outcomes. Their findings reveal that capturing the subjective pain experience may enable more effective pain management and reduce the likelihood of CPSP after surgery. Overview of chronic CPSP and study goals CPSP affects up to 25% of patients after surgery, posing a considerable burden on healthcare systems and significantly diminishing quality of life. Traditionally, high levels of acute postoperative pain have been correlated with CPSP risk. However, psychological factors such as anxiety, depression, and pain catastrophizing also contribute to the development of CPSP. Recognizing this complexity, the authors sought to determine whether a patient’s subjective pain experience, measured through a validated patient-reported outcome tool, might serve as a more effective predictor of CPSP than pain intensity alone. Key findings Conducted as a secondary analysis within a multicenter clinical trial of 294 orthopedic surgery patients, this study utilized the Evaluation du Vecu de l’Anesthésie Générale (EVAN-G) questionnaire to assess patient pain experience. Key findings include: Pain experience as a predictor: Out of 219 patients with complete data, 63 (29%) developed CPSP 90 days post-surgery. Those who reported a poorer pain experience on the EVAN-G pain dimension on the second postoperative day were significantly more likely to develop CPSP. This outcome highlights the predictive value of the subjective pain experience, with patients who scored poorly on the pain dimension showing an increased risk. Limited role of pain intensity: In multivariate analysis, once the pain experience variable was included, acute pain intensity lost its predictive significance for CPSP. Instead, pain experience—capturing […]
December 17, 2024
