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Dexamethasone or corticosteroids for postoperative pain management are broadly studied. Its postoperative analgesics effects have been demonstrated but evidence regarding the optimal dose is scarce. Some investigators indicate that high doses of corticosteroids might improve pain relief, but fear of side-effects limit their use. The goal of the present systematic review with meta-analysis of randomized-controlled trials was to asses efficacy and safety of high dose corticosteroids (≥15mg) for postoperative pain relief We consider our results of special interest for anaesthesiologist, surgeons and pain specialists since our observations can have a significant impact on the daily management of postoperative pain.

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Introduction: An individualised thromboprophylaxis was implemented in critically ill patients suffering from coronavirus disease 2019 (COVID-19) pneumonia to reduce mortality and improve clinical outcome. The aim of this study was to evaluate the effect of this intervention on clinical outcome. Methods: In this mono-centric, controlled, before-after study, all consecutive adult patients with confirmed COVID-19 pneumonia admitted to ICU from March 13th to April 20th 2020 were included. A thromboprophylaxis protocol, including augmented LMWH dosing, individually tailored with anti-Xa measurements and twice-weekly ultrasonography screening for DVT, was implemented on March 31th 2020. Primary endpoint is one-month mortality. Secondary outcomes include two-week and three-week mortality, the incidence of VTE, acute kidney injury and continuous renal replacement therapy (CRRT). Multiple regression modelling was used to correct for differences between the two groups. Results: 46 patients were included in the before group, 26 patients in the after group. One month mortality decreased from 39.13% to 3.85% (p < 0.001). After correction for confounding variables, one-month mortality was significantly higher in the before group (p = 0.02, OR 8.86 (1.46, 53.75)). The cumulative incidence of VTE and CRRT was respectively 41% and 30.4% in the before group and dropped to 15% (p = 0.03) and 3.8% (p = 0.01), respectively. After correction for confounding variables, risk of VTE (p = 0.03, 6.01 (1.13, 32.12)) and CRRT (p = 0.02, OR 19.21 (1.44, 255.86)) remained significantly higher in the before group. Conclusion: Mortality, cumulative risk of VTE and need for CRRT may be significantly reduced in COVID-19 patients by implementation of a more aggressive thromboprophylaxis protocol. Future research should focus on confirmation of these results in a randomized design and on uncovering the mechanisms underlying these observations.

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An alternative strategy for COVID-pneumonitis: a retrospective analysis from a tertiary center in Belgium Background: At the start of the COVID-19 pandemic in Europe no clear guidelines on its treatment were available. While early intubation and the avoidance of steroids was proposed, an alternative strategy of non-invasive ventilation and steroid use in case of refractory hypoxemia after one week was implemented to decrease the burden on resources. This single center retrospective analysis assessed the feasibility and safety of such a strategy. Methods: All patients admitted to the ICU with a confirmed COVID-19 pneumonitis from March to June 2020 were included in the analysis. Multivariable logistic regression was done to assess (1) the feasibility of ICU mortality prediction by the Charlson Comorbidity Index and the Clinical Frailty Score (2) the impact of invasive mechanical ventilation and steroid administration in ICU mortality. Results: 97 patients were admitted to the ICU. Mean APACHE-III was 67 (16), with a predicted ICU mortality of 30%. Median P/F ratio was 91 (IQR 67-118) on admission. Only 37 (40%) patients were intubated and mechanically ventilated within their ICU stay. The ICU mortality rate was 20.6% (n=20). The multivariable logistic regression model for ICU mortality, using gender, Charlson Comorbidity Index and Clinical Frailty Score had an AUROC of 0.81, with an R² of 0.23. Thirty eight patients (39%) of 97 patients received steroids. Adding steroid administration to the multivariable model did not yield the latter as an independent factor of ICU-mortality (p=0.06). However, mechanical ventilation remained an independent risk factor for ICU-mortality (p=0.004) with an odds ratio of 9.9 (95%CI 1.8-53.6), after adjustment for baseline risk factors Charlson Comorbidity Index, Clinical Frailty Score and APACHE-III score. Conclusions: This single center retrospective analysis demonstrated a safe alternative strategy using a non-invasive ventilation strategy and late administration of steroids. These findings need to be confirmed in multi-center prospective randomised controlled trials.  

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Abnormal postpartum hemorrhage is a common problem, complicating 3-5% of vaginal and operative deliveries. In a majority of cases (98%) uterine atony, retained placenta or genital tract lacerations are responsible for excessive blood loss. However, occasionally, serious coagulopathy may occur early after delivery or in specific circumstances such as with placental abruption. Also, when bleeding is caused by uterine atony, retained placenta or vaginal lacerations, a dilutional coagulopathy may develop. Hence correcting coagulation abnormalities is often required. Crucial to manage postpartum coagulopathy is the use of tranexamic acid to reduce hyperfibrinolysis. In the present narrative review, we will discuss the use of tranexamic acid for the prevention and management of major postpartum hemorrhage by reviewing the available literature.

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Background: Moderate to severe postoperative pain remains a problem for patients undergoing caesarean sections. A multimodal analgesia regimen, as recommended by the PROSPECT guidelines, includes the administration of dexamethasone. Previous studies have shown correlations between high-dose dexamethasone administration and improved postsurgical analgesia in addition to the antiemetic effects of the drug. Objectives: The intention of this double-blind randomized controlled trial is to compare a high- and a low-dose of dexamethasone when added to a multimodal analgesia regimen in the postoperative setting after a caesarean section. This thesis focusses on the association between predisposing factors for and effects on the need for rescue medication for pain. Methods: The study protocol was approved by both the Central Ethics Committee and the national regulatory authorities (EudraCT 2020-005681-33). Seventy-five patients were included before January 31, 2022, and randomly allocated in the high-dose (two doses of 25 mg dexamethasone) or the low-dose group (one dose of 5 mg dexamethasone and one dose of placebo). We performed a blinded interim analysis of this randomized controlled trial. All patients, independent of their assigned groups, were divided in two groups based on their use of rescue analgesics. Possible predictive factors for the use of rescue analgesics were investigated, in addition to possible implications of this drug use. Results: A total of 43 patients (57%) had a need for rescue analgesics. No predictive factors for rescue analgesic use could be determined from collected pre- and intraoperative data. Patients who required rescue analgesia during this trial experienced more postoperative pain on multiple timepoints in the postpartum period. Breastfeeding was not influenced by the experience of post caesarean pain but a negative association between postoperative pain and patient recovery was found. Patients in need of additional rescue analgesia also scored lower on a patient satisfactory numerical rating scale. No patients were diagnosed with delirium during the follow up period. Conclusion: Postoperative pain is a clear precipitating factor for rescue analgesia use and post caesarean pain has a clear negative effect on the patient recovery and analgesia satisfaction. Strong indications were found that a dose of 25 mg dexamethasone does not cause delirium in our patient population.