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We show a systematic review of known complications during intraoperative neuromonitoring (IONM) using transcranial electric stimulation motor evoked potentials (TES-MEP) on cervical spine surgery, which provides a summary of the main findings. A rare complication during this procedure, cardiac arrest by cardioinhibitory reflex, is also described.Findings of 523 scientific papers published from 1995 onwards were reviewed in the following databases: CENTRAL, Cochrane Library, Embase, Google Scholar, Ovid, LILACS, PubMed, and Web of Science. This study evaluated only complications on cervical spine surgery undergoing TES-MEP IONM.The review of the literature yielded 13 studies on the complications of TES-MEP IONM, from which three were excluded. Five studies are case series; the rest are case reports. Overall, 169 complications on 167 patients were reported in a total of 38,915 patients, a global prevalence of 0.43%. The most common complication was tongue-bite in 129 cases, (76.3% of all complication events). Tongue-bite had a prevalence of 0.33% (CI 95%, 0.28-0.39%) in all patients on TES-MEP IONM. A relatively low prevalence of severe complications was found: cardiac-arrhythmia, bradycardia and seizure, the prevalence of this complications represents only one case in all the sample. Alongside, we report the occurrence of cardiac arrest attributable to TES-MEP IONM.This systematic review shows that TES-MEP is a safe procedure with a very low prevalence of complications. To our best knowledge, asystole is reported for the first time as a complication during TES-MEP IONM.

Background Extragonadal choriocarcinoma is rare and can be associated with hyperthyroidism when producing very high levels of human chorionic gonadotropin. Case presentation A 62-year-old Hispanic female presented with a 3-week history of shortness of breath, palpitations, extreme weakness, new-onset hot flashes, and right flank pain. Her physical examination was remarkable for tachycardia, hepatomegaly, hyperreflexia, and tremor; goiter was absent. Laboratory studies revealed increased lactate dehydrogenase, alkaline phosphatase, suppressed thyroid stimulating hormone, very elevated T4, and absent thyroid stimulating immunoglobulin. 18F-fluorodeoxyglucose positron emission tomography-computed tomography exhibited hepatomegaly with multiple large fluorodeoxyglucose-avid liver masses and a focus of fluorodeoxyglucose avidity in the stomach with no structural correlate. A thyroid scan (99mTcO 4 − ) showed diffusely increased tracer uptake. She was started on propranolol and methimazole. Upon stabilization of severe thyrotoxicosis, upper endoscopy was performed, showing a ~ 5 cm bleeding lesion in the greater stomach curvature body; biopsy was consistent with choriocarcinoma; beta-human chorionic gonadotropin hormone was 2,408,171 mIU/mL. The patient received methotrexate followed by etoposide and cisplatin. Methimazole was titrated down, and upon liver failure the medication was stopped. The thyrotoxicosis was effectively controlled with antithyroid drug and concurrent chemotherapy. At ~ 1.5 months after initial diagnosis, the patient died due to bleeding/acute liver failure with coagulation defects followed by multiple organ failure. Conclusions Severe thyrotoxicosis can represent an unusual initial presentation of metastatic choriocarcinoma in the setting of extreme elevation of beta-human chorionic gonadotropin. Primary gastric choriocarcinoma is an aggressive malignancy with very poor outcomes. The co-occurrence of severe thyrotoxicosis with advanced primary gastric choriocarcinoma and imminent liver failure complicates management options.

Objective: To determine the impact and usefulness of the combination of structural and functional biomarkers in the diagnosis of acute renal injury (AKI) and short-term prognosis of patients undergoing cardiac surgery (CS). Material and Methods. Prospective cohort study (March 2018 to December 2019). 63 adults older than 18 years old, on the Intensive Care Unit (ICU) were included. Interventions: Patients had undergone CS with extracorporeal circulation (ECC). Surgery was elective in 80% of cases; it was urgent in 18% and emergent in 3%. Exclusion criteria included chronic kidney disease, contrast medium application ≤24 hour before surgery, cancer, infectious and autoimmune diseases. On admission to the ICU, serum creatinine, urinary creatinine, urinary sediment, urinary NGAL, urinary cystatin, microalbuminuria and serum cystatin were measured. Results. AKI was found 31 cases (49%). ECC without renal damage was found when time of extracorporeal circulation was of 85 ± 25 minutes and with renal damage when it lasted 114 ± 32 (p = 0.0001). Serum creatinine has a likelihood ratio (LR) + of 5.5, the combination of serum cystatin c (cystatin C) and normalized NGAL, showed a better LR. In patients with severe irreversible AKI, the combination of cystatin C + NGAL adjusted to urinary creatinine (NGAL/uCr) + microalbuminuria had a LR+ of 18.75 and LR - of 0.26. Conclusions: The combination of biomarkers predicts and identifies severity of AKI and Biomarkers combination in Cardiac Surgery

Background: Septic shock is the most serious form of sepsis and can be due to several factors, such as hypovolemia, vascular hyporesponsiveness, myocardial dysfunction, or dysfunction of the circulation. Likewise, electrolyte levels have been associated with septic shock in intensive care units, although it has been underdiagnosed. Based on this, the purpose of the present work was to evaluate plasma ionic levels in patients with septic shock before and after treatment with different antioxidants. Methods: Plasma ionic levels were measured (Na+, K+, Cl- and ionized Ca2+ and Mg2+) in 194 subjects, 129 healthy control patients, 14 patients with septic shock without treatment and 51 patients with septic shock under treatment with 4 different antioxidants (N-acetyl cysteine, melatonin, vitamin C and vitamin E). Results: We found important differences when comparing the plasma ionic levels of K+, Ca2+ and Mg2+ between the control group versus in both groups with sepsis at the time of hospital admission. In patients with septic shock, there is a decrease in the serum levels of ionized Na+, K+, Cl- and Ca2+ and Mg2+. Antioxidant treatment as an adjunct to the standard management of patients with septic shock increases the electrolyte deficit. The correction of the magnesium deficit also leads to an increase in serum calcium and potassium levels. Conclusion: The management of antioxidant therapy in patients with septic shock within the first hours of admission can help to improve their ionic levels of Ca2+ and Mg2+, mainly in patients with lung damage.Clinical Trial gov registration: NCT03557229. Registered june 14, 2018. https://clinicaltrials.gov/ct2/show/NTC03557229?term=aISA+ALFREDO&draw=2&rank=1

Background and objectives: Oxidative stress (OS) participates in the pathophysiology of septic shock, which leads to multiple organ failure (MOF), ischemia-reperfusion injury, and acute respiratory distress syndrome. Therefore, antioxidants have been proposed as therapy. Here, we evaluated the effect of antioxidant treatments in patients with septic shock with MOF and determined levels OS before and after treatment. This study was a randomized, controlled, triple-masked, and with parallel assignment clinical trial with a control group without treatment. Materials and Methods: It included 97 patients of either sex with septic shock. 5 treatments were used each in an independent group of 18 patients. Group 1 received vitamin C (Vit C), group 2 vitamin E (Vit E), group 3 n-acetylcysteine (NAC), group 4 melatonin (MT), and group 5 served as control. All antioxidants were administered orally or through a nasogastric tube for five days as an adjuvant to the standard therapy. Results: The results showed that all patients presented MOF due to sepsis upon admission and that the treatment decreased it (p = 0.007). The antioxidant treatment with NAC increased the total antioxidant capacity (p &lt, 0.05). The patients that received Vit C had decreased levels of the nitrate and nitrite ratio (p &lt, 0.01) and C-reactive protein levels (p = 0.04). Procalcitonin levels were reduced by Vit E (p = 0.04), NAC (p = 0.001), and MT (p = 0.04). Lipid-peroxidation was reduced in patients that received MT (p = 0.04). Conclusions: In conclusion, antioxidant therapy associated with standard therapy reduces MOF, OS, and inflammation in patients with septic shock.

Background: Oxidative stress (OS) participates in the pathophysiology of patients with septic shock having multiple organ failure (MOF), ischemia-reperfusion injury and acute respiratory failure syndrome (ARDS). Antioxidants have been proposed in their therapy.Objective: To evaluate the effect of antioxidant treatment in patients with septic shock with MOF and levels OS after treatment.Research question: Will the administration of specific antioxidant therapy decrease deregulatory factors of oxidative stress and organ failure in patients with septic shock?Study design and Methods: Double-blind, placebo-controlled randomized clinical trial run in 2 ICU in Mexico City between May 2018 and January 2020. The random allocation sequence was generated using computer methods. Patients older than 18 years of either sex, with septic shock were included, were excluded when informed consent could not be obtained, they received chronic or recent use of steroids, statins, or antioxidants or if they had contraindications to the use of antioxidants. All antioxidants were administered by mouth or nasogastric tube during 5 days and were added to standard.Results: 97 patients were included with median age of 66 years. 20 were treated with MT and 18 with Vit C and they showed post-treatment decreased SOFA scores [p=0.007 and p3−/NO2− (p=0.02) and RCP levels [p=0.045]. Procalcitonin (PCT) levels were reduced by Vit E, [p=0.047], NAC; [p=0.001] and MT [p=0.045]. LPO was reduced in patients that received MT p=0.042 Conclusion: In septic shock, antioxidant therapy associated with standard intensive care unit therapy reduces MOF, the oxidative and inflammatory state. These results could be a reference to use adjuvant antioxidant therapy in patients with septic shock in COVID19.Trial Registration: ClinicalTrials.gov Identifier: NCT 03557229

Background Aneurysmal subarachnoid hemorrhage (ASAH) is a serious and unstable condition. Patient safety indicators (PSI) are a group of potentially preventable events in patient health care. The aim of this study is to determine the prevalence of 8 relevant PSI in a group of patients with ASAH and their relation with 2 health care outcomes. Methods We performed a retrospective review of all patients admitted with ASAH. A total of 35 patients were selected with the following variables: age, sex, Hunt and Hess scale at admission, brain aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale (GOS) score with the presence or absence of all 8 PSI: decubitus ulcer, pneumothorax, bacteremia, perioperative hematoma, postoperative respiratory failure, deep vein thrombosis (DVT), pulmonary thromboembolism, and accidental puncture or laceration. Results Average age (±standard deviation) was 53 ± 13.9 years, with a female predominance of 63%. The most common PSI was decubitus ulcer followed by central line-related bacteremia. Prolonged hospital stay was increased for inpatients with DVT. Males had a risk effect (odds ratio, 6.25) in relation to the appearance of pulmonary thromboembolism as well as a poor neurologic condition according to the GOS (GOS score Conclusions In our study population, we found 3 PSI related to a poor outcome measured with the GOS or to a longer hospital stay: decubitus ulcer, central line-related bacteremia, and DVT. PSI have been academically considered as useful tools in clinical, epidemiologic, and research outcome scenarios. An adequate prevention protocol for these indicators could produce better outcomes in medical care for patients with ASAH.