Rocuronium and sugammadex for rapid sequence induction of obstetric general anaesthesia

Background: Many anaesthetists use rocuronium in place of suxamethonium for rapid sequence induction (RSI). This is less common in obstetric anaesthesia as the duration of action of an effective dose of rocuronium exceeds most obstetric procedures. Sugammadex offers the possibility of rapidly reversing profound rocuronium neuromuscular blockade at the end of surgery. We aimed to determine whether rocuronium 1.2 mg/kg used for RSI in the obstetric population would provide good intubating conditions at 60 s and would be effectively reversed by sugammadex at the end of surgery. Methods: We present a prospective series of 18 patients who received rocuronium 1.2 mg/kg at induction of anaesthesia, monitored with a train‐of‐four ratio (TOF)‐Watch SX^®, and reversed using sugammadex 4 mg/kg. Results: The mean (95% CI) onset time of rocuronium was 71 (56–86) s, and the mean (95% CI) time to recovery of the TOF to ≥90%, after the administration of sugammadex 4 mg/kg at the end of surgery, was 86 (69–104) s. Conclusion: Rocuronium 1.2 mg/kg reversed by sugammadex appears to be effective in the obstetric population.     

Four years' experience of a ROTEM®-guided algorithm for treatment of coagulopathy in obstetric haemorrhage

We report four years of observational data from a large UK hospital and tertiary referral unit, following the introduction of a rotational thromboelastometry-guided algorithm for treatment of coagulopathy in major obstetric haemorrhage. Fibrinogen concentrate was used to treat acquired hypofibrinogenaemia as defined by a FibTEM A5 value of < 7 mm, or 7–12 mm with ongoing or high risk of haemorrhage. Of 32,647 deliveries over 4 years, 893 (2.7%) women had an estimated blood loss ≥ 1500 ml. Two-hundred and three (23%) of these had a FibTEM A5 ≤ 12 mm and 110 received fibrinogen concentrate. We compared clinical outcomes and blood product use with 52 patients who met the same criteria, over a 12-month pre-intervention period during which shock packs were used. In the algorithm group, there was a significant reduction in the number of units (p < 0.0001) and total volume (p = 0.0007) of blood products transfused, with a reduction in transfusion-associated circulatory overload (p = 0.002). Women with placental abruption exhibited more severe coagulopathy and required higher doses of fibrinogen concentrate than women who bled due to other causes. Analysis of rotational thromboelastometry results demonstrated that coagulopathy is not observed in all women who suffer obstetric haemorrhage and cannot be predicted solely by blood loss. Therefore, formulaic treatment with blood products is not justified. When coagulopathy does occur, it appears to be multifactorial and can be severe. Point-of-care testing allows early identification and individualised treatment of coagulopathy. This is supported by the improved outcomes reported.     

iNICU – Integrated Neonatal Care Unit: Capturing Neonatal Journey in an Intelligent Data Way

Neonatal period represents first 28 days of life, which is the most vulnerable time for a child’s survival especially for the preterm babies. High neonatal mortality is a prominent and persistent problem across the globe. Non-availability of trained staff and infrastructure are the major recognized hurdles in the quality care of these neonates. Hourly progress growth charts and reports are still maintained manually by nurses along with continuous calculation of drug dosage and nutrition as per the changing weight of the baby. iNICU (integrated Neonatology Intensive Care Unit) leverages Beaglebone and Intel Edison based IoT integration with biomedical devices in NICU i.e. monitor, ventilator and blood gas machine. iNICU is hosted on IBM Softlayer based cloud computing infrastructure and map NICU workflow in Java based responsive web application to provide translational research informatics support to the clinicians. iNICU captures real time vital parameters i.e. respiration rate, heart rate, lab data and PACS amounting for millions of data points per day per child. Stream of data is sent to Apache Kafka layer which stores the same in Apache Cassandra NoSQL. iNICU also captures clinical data like feed intake, urine output, and daily assessment of child in PostgreSQL database. It acts as first Big Data hub (of both structured and unstructured data) of neonates across India offering temporal (longitudinal) data of their stay in NICU and allow clinicians in evaluating efficacy of their interventions. iNICU leverages drools based clinical rule based engine and deep learning based big data analytical model coded in R and PMML. iNICU solution aims to improve care time, fills skill gap, enable remote monitoring of neonates in rural regions, assists in identifying the early onset of disease, and reduction in neonatal mortality.     

Immunotoxic effects of gold and silver nanoparticles: Inhibition of mitogen-induced proliferative responses and viability of human and murine lymphocytes in vitro

Understanding the effects of nanoparticles (NP) on immune cell functions is essential in designing safe and effective NP-based in vivo drug delivery systems. The immunomodulatory potential of gold nanoparticles (GNP) and silver nanoparticles (SNP) was investigated in vitro using murine splenic and human peripheral blood lymphocytes (PBL) in terms of effects on viability and mitogen-induced proliferation. Hydrodynamic size and number of NP were characterized using NP tracking analysis (NTA); modal diameters of GNP and SNP were 28 (±1.5) and 66 (±?2.7) nm, respectively, with a unimodal distribution. Lymphocytes were incubated with GNP or SNP in the presence/absence of B- or T-cell mitogens and proliferative responses then determined using [³H]-thymidine incorporation. Concanavalin A (T-cell-specific) and lipopolysaccharide- (B-cell-specific) stimulated responses of murine splenic lymphocytes, as well as phytohemagglutinin (T-cell-specific) and pokeweed mitogen- (B-and T-cell specific) induced responses of human lymphocytes, were significantly inhibited by GNP (25–200?μg/ml) and SNP (12.5–50?μg/ml). However, [³H]-thymidine incorporation by unstimulated lymphocytes was unaffected in the presence of GNP or SNP. Viability of lymphocytes was determined using trypan blue dye exclusion and was significantly inhibited only at 200 μg GNP/ml and 25 or 50?μg SNP/ml. As mitogen responses are most useful to provide supportive mechanistic information on primary immunotoxicologic functional observations, and so far more comprehensive data (in vivo and in vitro) is still needed, the results nevertheless suggest to us that GNP and SNP might potentially be able to modulate immune responses by impacting on lymphocyte activation.     

iCHRCloud: Web &amp; Mobile based Child Health Imprints for Smart Healthcare

Reducing child mortality with quality care is the prime-most concern of all nations. Thus in current IT era, our healthcare industry needs to focus on adapting information technology in healthcare services. Barring few preliminary attempts to digitalize basic hospital administrative and clinical functions, even today in India, child health and vaccination records are still maintained as paper-based records. Also, error in manually plotting the parameters in growth charts results in missed opportunities for early detection of growth disorders in children. To address these concerns, we present India’s first hospital linked, affordable automated vaccination and real-time child’s growth monitoring cloud based application- Integrated Child Health Record cloud (iCHRcloud). This application is based on HL7 protocol enabling integration with hospital’s HIS/EMR system. It provides Java (Enterprise Service Bus and Hibernate) based web portal for doctors and mobile application for parents, enhancing doctor-parent engagement. It leverages highchart to automate chart preparation and provides access of data via Push Notification (GCM and APNS) to parents on iOS and Android mobile platforms. iCHRcloud has also been recognized as one of the best innovative solution in three nationwide challenges, 2016 in India. iCHRcloud offers a seamless, secure (256 bit HTTPS) and sustainable solution to reduce child mortality. Detail analysis on preliminary data of 16,490 child health records highlight the diversified need of various demographic regions. Thus, primary lesson would be to implement better validation strategies to fulfill the customize requisites of entire population. This paper presents first glimpse of data and power of the analytics in policy framework.     

Galectin-3 in urine of cancer patients: stage and tissue specificity

Purpose  Galectin-3 has been implicated in advanced stage of cancer disease. In the current study we examined the possibility of urinary galectin-3 levels to stage cancer disease and to follow up therapy. Experimental design  Urine was collected from all types of cancer patients at different stages including patients undergoing radio/chemotherapy. Galectin-3 level was determined by anti-galectin-3 based ELISA and agglutination assays. Immunoblotting and purification on lactosyl affinity column further confirmed the presence of galectin-3. Results  Cancer samples exhibited stage dependent expression of galectin-3 approx. ranging from 1.0 to 3.3, 4.4 to 5.4, 5.4 to 24.7, 13.1 to 31.9, 13.9 to 32.9 ng/mg C (creatinine) for stage I–V, respectively, at P ~ <0.05 level. Galectin-3 levels were decreased by approx. threefolds after 5th day of therapy. Conclusions  Sample collection being simple and non-invasive, urinary galectin-3 may be used as a potential diagnostic tool for monitoring or follow up of the stage of cancer disease.     

The economic benefits of cell salvage in obstetric haemorrhage

BackgroundCell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period.MethodCell salvage was introduced in the Liverpool Women’s NHS Foundation Trust in 2006. Data were collected from all cases in which it was set-up and included the volume of blood processed and returned and whether surgery was elective or emergency.ResultsBetween 1st January 2006 and 30th June 2011, cell salvage for collection was set-up 587 times and blood was returned in 137 patients. Total volume of blood returned was 47 143 mL, equivalent to 189 units of packed red cells. The return rate was higher for emergency than elective cases (P = 0.03). As the use of cell salvage has extended over time to include a greater proportion of patients, return rates have decreased (P < 0.0001). The volume of blood returned from cell salvage was significantly related to the estimated blood loss (P < 0.00001), with a best fit line described by estimated blood loss = 3.45x + 454, where x was the volume of blood returned. In 2011 total costs of cell salvage were £9245 for the equivalent of 83 units of blood. At the current price of £125 per unit of allogeneic blood this would have cost £10 375: a saving of £1130. No intraoperative or postoperative complications associated with cell salvage were seen.ConclusionThe routine use of cell salvage was associated with more salvaged blood being returned to patients, which offset the cost of collection sets when compared to the cost of using allogeneic blood. Cell salvage is an appropriate expenditure to reduce the use of allogeneic blood.