Author: Grabs, Anthony ; Lekich, Christopher K ; Bonython, Wendy ; De Maeseneer, Marianne ; Paraskevas, Peter ; Amos, Michael ; Jackson, Mark ; Gibson, Kathleen ; Ramelet, Albert-Adrien ; Simkin, Carlos ; Devereux, John A ; Iafrati, Mark ; Davies, Alun H ; Rogan, Christopher ; Lim, Adrian ; Gloviczki, Peter ; Connor, David E ; Rial, Rodrigo ; Jindal, Ravul ; Whiteley, Mark S ; Roberts, Stefania ; Hafner, Franz ; Parsi, Kurosh ; Marks, Lisa ; Lurie, Fedor ; Grillo, Lorena ; van Rij, Andre M ; Thibault, Paul K ; Bozkurt, Ahmet Kursat ; Raymond-Martimbeau, Pauline ; Huber, David ; Gianesini, Sergio

Background Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. Objectives To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. Methods An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. Results Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. Conclusion Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

01 Nov 2024·CNS Neuroscience & Therapeutics

Steroids' Neuroprotective Potential in Severe Cerebral Venous Thrombosis: Experimental and Clinical Exploration of NLRP3 Inflammasome Inhibition

Article

Author: Hou, Limin ; Ji, Xunming ; Hu, Shuyuan ; Zhao, Haiping ; Luo, Yumin ; Liu, Guiyou ; Wang, Chunxiu ; Liu, Jia ; Duan, Jiangang ; Gu, Yaqin

ABSTRACTBackgroundNLRP3 inflammasome‐related inflammation might play an important role in the pathophysiology of severe CVT. The use of steroids as anti‐inflammatory agents in improving severe CVT prognosis remains controversial.MethodsA total of 94 male Sprague–Dawley rats were used. We evaluated the dynamic and association between NLRP3 inflammasome in brain, blood, and CSF and severity in severe CVT rats and/or patients. We also explored the effect of steroids on NLRP3 activation, neurological injury, and CSF circulation disturbance after CVT in animals and/or patients.ResultsIn rats, compared with the sham group, NLRP3‐related factors rose on day 1, peaked on day 2 (NLRP3, Sham: 0.79 ± 0.22; day 2: 1.25 ± 0.08, p < 0.01; pro‐Caspase‐1, Sham: 0.58 ± 0.13, day 2: 1.20 ± 0.44, p < 0.05; GSDMD, Sham: 0.94 ± 0.22, day 2: 1.72 ± 0.46, p < 0.05; pro‐IL‐1β, Sham: 0.74 ± 0.15, day 2: 1.35 ± 0.09, p < 0.01), decreased on day 7 in rats (n = 4 per group). Thrombus (Sham: 0.00 ± 0.00, day 2: 3.44 ± 0.70, p < 0.0001), infarct size (Sham: 0.00 ± 0.00, day 2: 11.99 ± 6.26, p < 0.01) and neurological deficits appeared similar trend. In 50 patients, serum NLRP3 and IL‐6 levels correlated positively with NIHSS (r = 0.4273, p = 0.0020; r = 0.4938, p = 0.0029) and mRS (r = 0.5349, p = 0.0125; r = 0.6213, p = 0.026), while CSF IL‐6 correlated positively with mRS on admission (r = 0.5349, p = 0.0125). Compared with baseline, NLRP3 (0.36 (0.36, 0.36) vs. 0.41 (0.37, 0.84), p < 0.0001) and IL‐6 decreased (4.06 ± 1.48 vs. 12.03 ± 7.80, p < 0.05), accompanying by improvement of neurological deficits and CSF circulation (all p < 0.01) after steroids therapy in severe CVT patients at discharge and 3 months follow‐up. No significant steroid‐related adverse effects were observed.ConclusionShort‐term steroid therapy may improve prognosis of severe CVT by suppressing NLRP3 inflammasome‐related inflammation.

01 Oct 2024·Pediatric Anesthesia

Preoperative survey to evaluate the patients' allergy list and its relevance to perioperative care

Article

Author: Redmond, Margaret ; Yemele Kitio, Sibelle Aurelie ; Rice‐Weimer, Julie ; Elmitwalli, Islam ; Khan, Farah N. ; Tobias, Joseph D.

AbstractIntroductionPerioperative hypersensitivity and allergic reactions can result in significant morbidity and mortality. For routine anesthetic care, allergies are determined from a review of the electronic medical record supplemented by a detailed patient history. Although the electronic medical record is generally assumed to be accurate, it may be that allergies are erroneously listed or not based on sound medical practice. The purpose of the current study is to evaluate allergies listed in the electronic medical record of children presenting for surgery and determine their origin, authenticity, and impact on perioperative care.MethodsEligible patients included those presenting for a surgical procedure in the main operating room, who were ≤ 21 years of age, with a drug allergy listed on the EMR. Prior to intraoperative care, an electronic survey questionnaire containing questions related to medication allergies was provided to a guardian or parent. Two anesthesiology physicians reviewed the survey responses to determine the validity of any reported allergies. A second electronic survey was given postoperatively to the attending anesthesiologist to determine whether the documented allergy impacted anesthetic care.ResultsThe study cohort included 250 patients, ranging in age from 5 to 14 years (median age 9 years). All of the patients had at least one allergy listed on the electronic medical record. Seventy of the 250 patients (28%) had more than one drug allergy listed for a total of 351 medication allergies. The majority of the listed allergies were related to antibiotics including 155 (44%) from the penicillin family, 26 (7%) cephalosporins, 16 (5%) sulfonamides, and 36 (10%) other antimicrobial agents. Other commonly listed allergies were 27 (8%) nonsteroidal anti‐inflammatory agents and 15 (4%) opioids. The remaining 76 (22%) included a miscellaneous list of other medications. On further review of the allergies, the survey was completed for 301 medications. After physician review, 135 of 301 (45%) responses were considered consistent with IgE reactions “true allergy,” 73 (24%) were deemed less relevant to IgE reactions “unlikely true allergy,” and 93 (31%) were not related to IgE reactions “not an allergy.” Care alterations during surgery were uncommon regardless of whether the issue was assessed as a true allergy (11%), unlikely to be a true allergy (3%), or not a true allergy (13%).ConclusionA significant portion of the documented allergies in children are not true allergies, but rather recognized adverse effects (apnea from an opioid, renal failure from an NSAIDs) or other nonallergic concerns (gastrointestinal upset such as nausea). Erroneously listed allergies may lead to unnecessary alterations in patient care during perioperative care. A careful analysis of the allergy list on the EMR should be supplemented by a thorough patient history with specific questions related to the drug allergy. Once this is accomplished, the allergy listed should be updated to avoid its erroneous impact on perioperative care.

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Indication	Highest Phase	Country/Location	Organization	Date
Arteriosclerosis	Discovery	US	DiaKine Therapeutics, Inc.	-
Nonalcoholic Steatohepatitis	Discovery	US	DiaKine Therapeutics, Inc.	-

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