Severe Dextran-Induced Anaphylactic Shock during Induction of Hypertension-Hypervolemia-Hemodilution Therapy following Subarachnoid Hemorrhage

Use of iron in perinatal anaemia: Indications for women’s health care policies and procedure

This paper reviews management of obstetric anaemia and the role of intravenous iron for the treatment of obstetric anaemia. Red blood cell transfusions are routinely used for haemoglobin restoration in anaemic women. The decision for red blood cell transfusion is made on a combination of haemoglobin level and clinical status, and it is suggested that transfusions are not necessary in those who are well compensated or when alternative therapy is available. To reduce the risk, intravenous iron infusion is proposed as a bloodless therapeutic approach. There are a variety of iron preparations. Intravenous iron infusion can reduce the requirement for blood transfusion in hemodynamically stable women with perinatal anaemia, especially in resource-scarce settings. It a cost-effective bloodless approach for the treatment of anaemia than can enhance patient outcomes. According to the literature, when haemoglobin is greater than 90 g/L, blood transfusion is not often required. In perinatal women with anaemia, the decision whether to administer blood or iron is based on patient preferences, haemoglobin levels, clinical symptoms, past and present medical conditions and the clinician’s judgement. Nevertheless, due to the lack of rigid criteria for blood transfusions in the majority of clinical settings, it is considered the default treatment for anaemia in perinatal women.

Contrast-induced acute kidney injury and its contemporary prevention

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Adult anaphylaxis: A state-of-the-art review

Anaphylaxis is the most severe among acute allergic diseases and potentially life threatening. Despite its increasing frequency and related burden, it remains often underdiagnosed and improperly managed. Its multisystemic involvement, protean clinical manifestations and its rapid onset are contributory factors. In recent years new acquisitions have shed light into its pathogenesis pathways (and related biomarkers), triggers, factors increasing its severity, along with peculiar clinical manifestations. These breakthrough discoveries have contributed to phenotyping and endotyping this disease, possibly paving the way to a personalized approach which is not available at present. Moreover, to disseminate awareness and standardize diagnostic criteria and management practices, several guidelines and consensus reports, albeit mainly intended for specialist care, have been issued. We here discuss the latest issues in the field of anaphylaxis from the perspective of the emergency and/or internal medicine physician, so to improve its early recognition and treatment in the acute setting and favor allergology referral to implement therapeutical and preventive strategies, such as allergen identification in unclear cases and desensitizing therapies when available (e.g., for Hymenoptera venom allergy).

Two cases of circulatory collapse due to suspected remimazolam anaphylaxis

Background

Remimazolam was approved in Japan in January 2020. We report two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction.

Case presentation

Case 1: A 74-year-old male was scheduled for debridement and skin grafting for a severe burn injury. We induced anesthesia with 4 mg of remimazolam and 20 mg of ketamine. The patient subsequently developed treatment-resistant severe hypotension.

Case 2: A 59-year-old male was scheduled for laparoscopic-assisted sigmoid colectomy. We induced anesthesia with 9 mg of remimazolam. Within a few minutes, the patient developed treatment-resistant severe hypotension.

As serum tryptase was elevated in both cases and only intravenous administration of adrenaline was effective, we considered the circulatory collapse might be due to anaphylaxis.

Conclusion

We experienced two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. The prevalence of remimazolam anaphylaxis is not yet known, and further research is needed.

Cytokine and Chemokine Recovery Is Increased by Colloid Perfusates during Dermal Microdialysis

Cytokines and chemokines play important roles in cell signalling, and microdialysis is a promising tool for monitoring these inflammation markers ex vivo. Therefore, the collecting of these mediators at the highest concentrations possible is crucial. Depending on the size of the mediator of interest, the collection of these high molecular mass molecules has thus far been difficult due to their low recovery, even when using high cut-off (100 kDa) microdialysis membranes. This study aimed to optimize the recovery of various cytokines and chemokines by validating the use of different perfusates in cutaneous microdialysis, and comparing intravenous (i.v.) colloids, crystalloids, and a lipid emulsion formulations that are approved for i.v. applications. Methods: In vitro and in vivo recovery experiments using six recombinant cytokines varying in molecular size (interleukin-2 (15 kDa), interleukin-6 (20.5 kDa), interleukin-8 (8 kDa), interleukin-12p70 (70 kDa), TNF-α (17.5 kDa), and vascular endothelial growth factor (VEGF) (38 kDa)) were performed in the presence of different perfusates for i.v. applications: Ringer’s lactate, dextran 60 kDa, hydroxyethyl starch 70 kDa, and hydroxyethyl starch 200 kDa solutions as well as a lipid emulsion formulation. Recovery was determined through (i) microdialysis of cytokines and chemokines in Ringer’s lactate solution or human serum in vitro, and (ii) retrodialysis of excised porcine and human skin cadavers in vitro and porcine skin in vivo. Furthermore, we used skin trauma (catheter insertion) and Ultraviolet B irradiation of 3 × 3 cm² skin areas to sample cytokines and chemokines in vivo and compared the amounts that were obtained using crystalloid and colloid perfusates. All the cytokines and chemokines within the dialysates were quantified through a flow cytometry-based bead array assay. Results: Overall, recovery was strongly increased by the colloids, particularly hydroxyethyl starch 70 kDa, in vitro, ex vivo, and in vivo. When compared with the recovery achieved using Ringer’s lactate, this increase was most effective for proteins ranging from 8 to 20.5 kDa. Hydroxyethyl starch 70 kDa significantly increased the recovery of interleukin (IL)-8 in human serum in vitro when compared with Ringer’s lactate. More cytokines and chemokines were recovered using colloids compared with crystalloids. However, the increase in recovery values was lower for IL-12p70 and VEGF. Conclusions: Regarding the dialysate volumes and final dialysate concentrations, colloid perfusates are overall superior to crystalloid perfusates, such as Ringer’s lactate, when sampling cytokines and chemokines, resulting in higher recoveries. However, the sampling of high-molecular-mass cytokines during microdialysis remains challenging, and experimental in vitro data are not completely comparable with data obtained ex vivo or in vivo.