Array
(
    [journal_recds] => Array
        (
            [0] => stdClass Object
                (
                    [j_id] => 13
                    [j_name] => Mathews Journal of Pediatrics
                    [j_url_name] => Pediatrics
                    [j_page_url] => pediatrics
                    [j_issn] => 2572-6560
                    [j_image] => mathews-journal-of-pediatrics1.jpg
                    [j_alttitle] => 2572-6560
                    [j_description] => <p><a href="https://www.mathewsopenaccess.com/journals/pediatrics"><strong>Mathews Journal of Pediatrics</strong></a>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which focuses on the studies related to the medical care of infants and children.</p>

<p>Mathews Journal of Pediatrics publishes papers on all ranges of cutting edge research conveyed in its field. The journal spotlights on the diseases affecting in children, child&#39;s Immunizations, and neonatal care. Aside from this, it covers development and specialized advances on different methodologies for the betterment of infant health care.</p>

<p>Mathews Journal of Pediatrics invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>
	<ul>
		<li>Neonatal Medicine</li>
		<li>Pediatric Blood and Cancer</li>
		<li>Pediatric Nephrology</li>
		<li>Pediatric Orthopaedics</li>
		<li>Preterm Infant</li>
		<li>New-born Screening</li>
		<li>Child Care</li>
		<li>Child Abuse</li>
		<li>Pediatric Pulmonology</li>
		<li>Developmental Disabilities</li>
		<li>Pediatric Surgery</li>
		<li>Child Development and Behaviour</li>
		<li>Perinatal Epidemiology</li>
		<li>BehaviouralPediatrics</li>
		<li>Paediatric Anaesthesia</li>
		<li>Paediatric Neurology</li>
		<li>Pediatric Cardiology</li>
		<li>Pediatric Radiology</li>
		<li>Pediatric Dermatology</li>
		<li>Pediatric Urology</li>
		<li>Pediatric Rheumatology</li>
		<li>Pediatric Rehabilitation</li>
	</ul>
	</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 12-08-2019
                    [name] => Bhaskar Narayan Rao,William-L-Nyhan,Liu Zhenhuan,Igor Klepikov,Khue Vu Nguyen
                    [country] => USA,USA,China,Israel,U.S.A
                    [page_url] => bhaskar-narayan-rao,william-l-nyhan,liu-zhenhuan,igor-klepikov,khue-vu-nguyen
                )

            [1] => stdClass Object
                (
                    [j_id] => 4
                    [j_name] => Mathews Journal of Neurology
                    [j_url_name] => Neurology
                    [j_page_url] => neurology
                    [j_issn] => 2572-6536
                    [j_image] => mathews-journal-of-neurology1.jpg
                    [j_alttitle] => 2572-6536
                    [j_description] => <p><strong>Mathews Journal of Neurology</strong>&nbsp;is an Open Access, companion checked on, worldwide accessed diary, which intends to distribute chief articles on all the related regions of cutting edge on clinical and essential science research carried out&nbsp;in the field of Neurology/ Neurosurgery and its interdisciplinary branches.</p>

<p>Mathews Journal of Neurology is to propel our comprehension of neurological malady to distinguish enhanced symptomatic and helpful strategies and systems for pediatric and grown-up population. It contains the study identified with structure, capacity and issue of sensory systems alongside the atomic and transformative angles. New disclosures in light of investigations of the study of disease transmission, etiology, component, counteractive action, analysis, restorative and surgical treatment and its result, and cell and sub-atomic examinations of disarranges influencing sensory systems are secured under the extension.</p>

<p>Mathews Journal of Neurology invites Research articles, Review articles, Short communications, Case reports, opinion articles, etc.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Neuro-muscular Disease</li>
	<li>Neuro-oncology</li>
	<li>Neuro-ophthalmology</li>
	<li>Neuro-otology</li>
	<li>Neuro-pathology</li>
	<li>Neuro-pharmacology</li>
	<li>Neuro-physiological Testing</li>
	<li>Neuro-psychology</li>
	<li>Neuro-rehabilitation</li>
	<li>Neuro-traumatology</li>
	<li>Neuro-vascular Diseases</li>
	<li>Neurological Infections</li>
	<li>Neuro-restoration and Resuscitation</li>
	<li>Neurotoxicology</li>
	<li>Sleep-Related Diseases</li>
	<li>Strokes</li>
	<li>Surgical Techniques and Instrumentations</li>
	<li>CSF Physiology / Hydrocephalus</li>
	<li>Congenital CNS Malformation</li>
	<li>Dementia and Memory Disorder</li>
	<li>Epileptology</li>
	<li>Headache and Pain Management</li>
	<li>Inflammatory and Demyelinating Diseases</li>
	<li>Interventional Neuro-radiology</li>
	<li>Intracranial Monitoring</li>
	<li>Molecular Diagnosis / Therapy</li>
	<li>Movement Disorder / Functional Neurosurgery</li>
	<li>Neuro-critical care</li>
	<li>Neuro-embryology</li>
	<li>Neuro-endocrinology</li>
	<li>Neuro-degenerative Diseases</li>
	<li>Neuro-imaging</li>
	<li>Pediatric Neurology / Neurosurgery</li>
	<li>Neuro-modulation</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Francisco López-Muñoz,Damir Janigro,Brenda Hanna-Pladdy,Liu Zhenhuan,Diego Liberati
                    [country] => Spain,USA,USA,China,Italy
                    [page_url] => francisco-l-pez-mu-oz,damir-janigro,brenda-hanna-pladdy,liu-zhenhuan,diego-liberati
                )

            [2] => stdClass Object
                (
                    [j_id] => 6
                    [j_name] => Mathews Journal of Cancer Science
                    [j_url_name] => Cancer
                    [j_page_url] => cancer
                    [j_issn] => 2474-6797
                    [j_image] => mathews-journal-of-cancer-science1.jpg
                    [j_alttitle] => 2474-6797
                    [j_description] => <p><strong>Mathews Journal of Cancer Science</strong>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which covers all parts of cancer investigation including crucial, preclinical, clinical, translational, sub-nuclear, epidemiological, evasion, treatment, and recuperation.</p>

<p>Mathews Journal of Cancer Science publishes pre-famous papers on all ranges of cutting edge research conveyed in its field. The journal spotlights on cell, sub-atomic, clinical and hereditary studies identified with illnesses. Aside from this it covers development and specialized advances on different methodologies for the treatment of cancer.</p>

<p>Mathews Journal of Cancer Science invites Research articles, Review articles, Short Reviews, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Nuclear Serine-Threonine Kinases</li>
	<li>PI3-Akt-mTOR Pathway</li>
	<li>Signal Transduction and Ubiquitin-related Pathway</li>
	<li>Cancer Therapy (Preclinical and clinical)</li>
	<li>Lung Cancer</li>
	<li>Breast Cancer</li>
	<li>Colorectal Cancer&nbsp;</li>
	<li>Hepatocellular Carcinoma</li>
	<li>Genitourinary Cancer</li>
	<li>Gynecologic Cancer&nbsp;</li>
	<li>Central Nervous System Tumors</li>
	<li>Head and Neck Cancer</li>
	<li>Cancer Biology&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li>
	<li>Tumor and Stem Cell Biology</li>
	<li>Microenvironment</li>
	<li>Molecular Targets</li>
	<li>Prognostic Factors and Radiation Biology</li>
	<li>Experimental Therapeutics</li>
	<li>Angiogenesis</li>
	<li>Cancer Stem Cell Pathway</li>
	<li>Cell Cycle and Checkpoints</li>
	<li>DNA Repair and Apoptosis</li>
	<li>Lymphoma</li>
	<li>Skin Cancers</li>
	<li>Cancer Prevention &amp; Epidemiology</li>
	<li>Cancer Genetics</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Chang-Ming Charlie Ma,Elena Batrakova,Evan T. Keller
                    [country] => United States,United States,United States
                    [page_url] => chang-ming-charlie-ma,elena-batrakova,evan-t-keller
                )

            [3] => stdClass Object
                (
                    [j_id] => 3
                    [j_name] => Mathews Journal of Case Reports
                    [j_url_name] => Case Reports
                    [j_page_url] => case-reports
                    [j_issn] => 2474-3666
                    [j_image] => mathews-journal-of-case-reports1.jpg
                    [j_alttitle] => 2474-3666
                    [j_description] => <p><strong>Mathews Journal of Case Reports</strong>&nbsp;is an Open Access, peer reviewed, online journal that publishes articles on all the significant parts of clinical and fundamental examination of research carried out in all aspects.</p>

<p>The scope of the journal underscores on the advancement of the research carried out in all aspects and the reports pertaining to it. It covers a wide range of subjects including medical, clinical, life science, biotechnology, pharmacy, microbiology, anatomy, physiology, etc.</p>

<p>Mathews Journal of Case Reports invites manuscripts on the topics related, but not limited to the following</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Gynaecological</li>
	<li>Gastrointestinal</li>
	<li>Anesthesia</li>
	<li>Cancer</li>
	<li>Neurology</li>
	<li>Immunology</li>
	<li>Pediatrics</li>
	<li>Dentistry</li>
	<li>Dermatology</li>
	<li>Pharmacy</li>
	<li>Radiology</li>
	<li>Endocrinology</li>
	<li>Orthopaedics</li>
	<li>Psychiatry</li>
	<li>Histology</li>
	<li>Cytology</li>
	<li>Nephrology</li>
	<li>Diabetes</li>
	<li>Veterinary</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Alexander B Norinsky,Hugh Koch,Giuseppe Lanza,Luciano Dias Zogbi
                    [country] => USA,UK,Italy,Brazil
                    [page_url] => alexander-b-norinsky,hugh-koch,giuseppe-lanza,luciano-dias-zogbi
                )

            [4] => stdClass Object
                (
                    [j_id] => 10
                    [j_name] => Mathews Journal of Psychiatry & Mental Health
                    [j_url_name] => Psychiatry Mental health
                    [j_page_url] => psychiatry-mental-health
                    [j_issn] => 2474-7564
                    [j_image] => mathews-journal-of-psychiatry-mental-health1.jpg
                    [j_alttitle] => 2474-7564
                    [j_description] => <p><strong>Mathews Journal of Psychiatry and Mental Health</strong>&nbsp;is an international, Open Access, peer reviewed journal that expects to publish quality research papers on the cutting edge research carried on psychiatry and mental health.</p>

<p>The scope of the journal is to underwrite the propelled flow research on study, diagnosis, treatment, and prevention of mental disorders which include various affective, behavioural, cognitive and perceptual abnormalities.</p>

<p>Mathews Journal of Psychiatry and Mental Health invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as submissions.</p>

<p><strong>Scope of Journal</strong></p>

<ul>
	<li>
	<ul>
		<li>Mental Health</li>
		<li>Mental Disorder</li>
		<li>Mental Illness</li>
		<li>Major Depression</li>
		<li>Personality Disorder</li>
		<li>Depressive Symptoms</li>
		<li>Anxiety Disorder</li>
		<li>Cognitive Impairment</li>
		<li>Multiple Sclerosis</li>
		<li>Atypical Antipsychotics</li>
		<li>Central Nervous System</li>
		<li>Prospective Study</li>
		<li>Mental Retardation</li>
		<li>Suicidal Ideation</li>
		<li>Logistic Regression</li>
		<li>Antidepressants</li>
		<li>Mood and Anxiety</li>
		<li>Clinical Psychology</li>
		<li>Dementia</li>
		<li>Bipolar Disorders</li>
		<li>Neuropsychopharmacology</li>
		<li>Alzheimer&#39;s Disease</li>
		<li>Psychotherapy</li>
		<li>Dopamine</li>
	</ul>
	</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 
                    [name] => Sam Vaknin,Sergey Fadyushin, Karl Goodkin,Arcady A. Putilov
                    [country] => Russia ,Russia , USA ,Russia 
                    [page_url] => sam-vaknin,sergey-fadyushin,karl-goodkin,arcady-a-putilov
                )

            [5] => stdClass Object
                (
                    [j_id] => 5
                    [j_name] => Mathews Journal of Dentistry
                    [j_url_name] => Dentistry
                    [j_page_url] => dentistry
                    [j_issn] => 2474-6843
                    [j_image] => mathews-journal-of-dentistry1.jpg
                    [j_alttitle] => 2474-6843
                    [j_description] => <p><strong>Mathews Journal of Dentistry</strong>&nbsp;is an Open Access, peer reviewed, worldwide online distributed journal, which plans to distribute head papers on all the related zones of cutting edge research carried out in dental sciences and its related field.</p>

<p>Mathews Journal of Dentistry focuses on the progressions in the fields of dentistry and oral pit at a wide range. The diary likewise covers fundamental and clinical exploration territories including the study of disease transmission, behavioral sciences identified with dentistry, dental and oral wellbeing.</p>

<p>Mathews Journal of Dentistry invites Research articles, Review articles, Short Reviews, Case reports, Opinion articles, etc. as submissions.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Pediatric dentistry</li>
	<li>Orofacial lesions</li>
	<li>Oral microbiology</li>
	<li>Dental implants</li>
	<li>Oral physiology and pathology</li>
	<li>Dental caries</li>
	<li>Gums and Dental materials</li>
	<li>Dental germs and plaques</li>
	<li>Periodontics and Endodontics</li>
	<li>Orthodontics</li>
	<li>Oral and maxillofacial surgery</li>
	<li>Cosmetic dentistry</li>
	<li>General and laser dentistry</li>
	<li>Sedation dentistry</li>
	<li>Oral and dental diseases</li>
	<li>Salivary gland diseases</li>
	<li>Dental stem cells</li>
	<li>Prevention and treatment of oral diseases</li>
	<li>Oral hygiene and dental care</li>
	<li>Dental instrumentation</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Joseph P Graskemper ,Michael P Horan,Daniel Humberto Pozza ,Lawrence Lavery
                    [country] => USA,USA,Portugal ,USA
                    [page_url] => joseph-p-graskemper,michael-p-horan,daniel-humberto-pozza,lawrence-lavery
                )

            [6] => stdClass Object
                (
                    [j_id] => 17
                    [j_name] => Mathews Journal of Cytology and Histology
                    [j_url_name] => Cytology Histology
                    [j_page_url] => cytology-histology
                    [j_issn] => 2577-4158
                    [j_image] => mathews-journal-of-cytology-and-histology1.jpg
                    [j_alttitle] => 2577-4158
                    [j_description] => <p><strong>Mathews Journal of Cytology and Histology:</strong>&nbsp;Cytology is a branch of Life Science that deals with the structure, functioning and the Chemistry of &#39;Cell&#39;, a basic unit of the living organism. Histology is the study of microscopic anatomy of cells and tissues of living organism. The Journal improves the knowledge of understanding of cellular changes and disease conditions of cells and tissues related to plants and animals.</p>

<p>Mathews Journal of Cytology and Histology is an Open access journal, includes wide range of fields of discipline and aspires in publishing reliable source of information of novel discoveries and developments in all areas of cytology and histology.</p>

<p>Mathews Journal of Cytology and Histology invites Editorials, Research articles, Review articles, Short Reviews, Short communications, Case reports, Opinion articles, Image articles etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Cytology and Histology covers but not limited to the following</strong></p>

<ul>
	<li>Cytology</li>
	<li>Histology</li>
	<li>Histopathology</li>
	<li>Cytopathology</li>
	<li>Cytogenetics</li>
	<li>Cell growth</li>
	<li>Cell staining</li>
	<li>Cell biology</li>
	<li>Immunostaining</li>
	<li>Cell signaling</li>
	<li>Cell fractionation</li>
	<li>Cellular microbiology</li>
	<li>Cell physiology</li>
	<li>Cell disruption</li>
	<li>Cell adhesion</li>
	<li>Histostaining</li>
	<li>Immunofluorescence</li>
	<li>Histochemistry</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] =>  Pietro Scicchitano,Joseph N Aziz ,Andrew Charles Evered,Carla Lucini
                    [country] =>  Italy,New Zealand ,UK,Italy
                    [page_url] => pietro-scicchitano,joseph-n-aziz,andrew-charles-evered,carla-lucini
                )

            [7] => stdClass Object
                (
                    [j_id] => 19
                    [j_name] => Mathews Journal of HIV/AIDS
                    [j_url_name] => Hiv Aids
                    [j_page_url] => hiv-aids
                    [j_issn] => 2474-6916
                    [j_image] => mathews-journal-of-hiv-aids1.jpg
                    [j_alttitle] => 2474-6916
                    [j_description] => <p><strong>Mathews Journal of HIV/ AIDS&nbsp;</strong>is an Open Access Scientific Academic Journal that expects to keep researchers, clinicians, examiners, understudies, and general populace aware of AIDS-related information with an in number focus on principal, clinical and translational science furthermore on the investigation of ailment transmission and infirmity reckoning.</p>

<p>Mathews Journal of HIV/ AIDS goes for conveyed reliable wellspring of information on the exposures and current headways as original articles, review articles, case reports, and short reviews, etc related to AIDS/HIV. The Journal serves to see better about the HIV/AIDS sub disciplines study including clinical, physiological and nuclear level of the examination.</p>

<p>Mathews Journal of HIV/ AIDS welcomes Original articles, Research articles, Reviews, Case reports, Short communications, opinion articles, etc.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>History of HIV/AIDS</li>
	<li>Epidemiology of HIV/AIDS</li>
	<li>Signs and symptoms</li>
	<li>Structure and Genome of HIV</li>
	<li>Subtypes of HIV</li>
	<li>Diagnosis of HIV/AIDS</li>
	<li>CDC Classification System for HIV Infection</li>
	<li>HIV Disease Progression Rates</li>
	<li>Management of HIV/AIDS</li>
	<li>Prevention of HIV/AIDS</li>
	<li>HIV/AIDS Research</li>
	<li>WHO Disease Staging System</li>
	<li>Countries by AIDS Prevalence Rate</li>
	<li>Circumcision and HIV</li>
	<li>Economic Impact</li>
	<li>Sex Education</li>
	<li>HIV/AIDS Denialism</li>
	<li>HIV Drug Resistance Database</li>
	<li>HIV Superinfection</li>
	<li>Super AIDS</li>
	<li>AIDS Dementia Complex</li>
	<li>Tuberculosis Coinfection</li>
	<li>HIV-Associated Nephropathy</li>
	<li>HIV-Associated Lipodystrophy</li>
	<li>HIV-Associated Pruritus</li>
	<li>Gay Bowel Syndrome</li>
	<li>Diffuse Infiltrative Lymphocytosis Syndrome</li>
	<li>AIDS Defining Clinical Condition</li>
	<li>History of HIV/AIDS</li>
	<li>Epidemiology of HIV/AIDS</li>
	<li>Whoonga</li>
	<li>Antiviral Therapy</li>
	<li>Opportunistic Infections</li>
	<li>Alternative Medicine</li>
	<li>Human Retroviruses</li>
	<li>Molecular biology of HIV</li>
	<li>HIV vaccine research</li>
	<li>Molecular and cellular basis of HIV pathogenesis</li>
	<li>Molecularbiology, immunology, and pathogenesis</li>
	<li>HIV/HTLV epidemiology</li>
	<li>A variety of care settings: pathology, coinfections</li>
	<li>Current developments in HIV/AIDS-related policy</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Maria Susana Maritato,Xiaodong Ma,Eleonora C. V. Costa,Chung-Yi Chen
                    [country] => New York, China,Portugal,Taiwan
                    [page_url] => maria-susana-maritato,xiaodong-ma,eleonora-c-v-costa,chung-yi-chen
                )

            [8] => stdClass Object
                (
                    [j_id] => 18
                    [j_name] => Mathews Journal of Gynecology & Obstetrics
                    [j_url_name] => Gynecology Obstetrics
                    [j_page_url] => gynecology-obstetrics
                    [j_issn] => 2572-6501
                    [j_image] => mathews-journal-of-gynecology-obstetrics1.jpg
                    [j_alttitle] => 2572-6501
                    [j_description] => <p><strong>Mathews Journal of Gynecology &amp; Obstetrics</strong>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which covers all parts of medical practice dealing with the health of the female reproductive systems, breasts, pregnancy, childbirth, and the postpartum period.</p>

<p>Mathews Journal of Gynecology &amp; Obstetricsexpects to distribute most elevated quality material covering clinical, investigative and medicinal articles. Our journal is a freely accessed that publishes original articles on clinical way to deal with the determination and treatment of women health.</p>

<p>Mathews Journal of Gynecology &amp; Obstetrics invites Research articles, Review articles, Short Communications, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Gestational Age</li>
	<li>Pregnancy Complication</li>
	<li>Postmenopausal Women</li>
	<li>Pelvic Organ Prolapse</li>
	<li>Oral Contraceptive</li>
	<li>Caesarean Section</li>
	<li>Umbilical Cord</li>
	<li>Oxytocin</li>
	<li>Fetal Growth Restriction</li>
	<li>Menstrual Cycle</li>
	<li>Ectopic Pregnancy</li>
	<li>Maternal Mortality</li>
	<li>Premature Rupture of Membranes</li>
	<li>gestational diabetes mellitus</li>
	<li>Pregnancy Induced Hypertension</li>
	<li>Reproductive Health</li>
	<li>Pregnancy</li>
	<li>Ovarian Research</li>
	<li>Reproductive Biology</li>
	<li>Lactation</li>
	<li>Breastfeeding&nbsp;</li>
	<li>Fetal Growth</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Vladislav S. Baranov,Alexander Makatsariya,Mariano Martin-Loeches,Abdelmonem Awad Hegazy 
                    [country] =>  Saint-Petersburg, Russia,Russia,Valencia, Spain,Egypt
                    [page_url] => vladislav-s-baranov,alexander-makatsariya,mariano-martin-loeches,abdelmonem-awad-hegazy
                )

            [9] => stdClass Object
                (
                    [j_id] => 7
                    [j_name] => Mathews Journal of Ophthalmology
                    [j_url_name] => Opthalmology
                    [j_page_url] => opthalmology
                    [j_issn] => 2474-6932
                    [j_image] => mathews-journal-of-ophthalmology1.jpg
                    [j_alttitle] => 2474-6932
                    [j_description] => <p><strong>Mathews Journal of Ophthalmology&nbsp;</strong>is an Open Access, peer reviewed, online journal that publishes articles on all the significant parts of clinical and fundamental examination as well as research facility examinations for progression in comprehension to ophthalmologists. The Journal advances studies on hereditary qualities, the study of disease transmission and pathophysiology of eye and visual science.</p>

<p>The scope of the Journal underscore on the logical learning, inventive systems and disclosures making useful commitments to the conclusion, treatment and avoidance of eye issue and visual incapacities.</p>

<p>Mathews Journal of Ophthalmology invites Research articles, Review articles, Short communications, Case reports, Opinion articles, Editorials, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Vitreous Hemorrhage</li>
	<li>Angioid Streaks</li>
	<li>Choroidal Detachment</li>
	<li>Choroidal Melanoma</li>
	<li>Ichthyosis</li>
	<li>Anterior Chamber</li>
	<li>Hyphema</li>
	<li>Conjunctiva</li>
	<li>Allergic Conjunctivitis</li>
	<li>Pterygium</li>
	<li>Red Eye</li>
	<li>Connective Tissue Disorders</li>
	<li>Cornea</li>
	<li>Atopic Keratoconjunctivitis</li>
	<li>Bacterial Keratitis</li>
	<li>Refractive Disorders</li>
	<li>Band Keratopathy</li>
	<li>Contact Lens Complications</li>
	<li>Corneal Abrasion</li>
	<li>Corneal Ulcer</li>
	<li>Iris And Ciliary Body</li>
	<li>Crystalline Dystrophy</li>
	<li>Keratoconus</li>
	<li>Neurologic Disorders</li>
	<li>Ultraviolet Keratitis</li>
	<li>Ocular Rosacea</li>
	<li>Iris And Ciliary Body</li>
	<li>Stevens-Johnson Syndrome</li>
	<li>Ophthalmologic Manifestations</li>
	<li>Graves Disease</li>
	<li>Pituitary Apoplexy</li>
	<li>Extraocular Muscles</li>
	<li>Acquired Esotropia</li>
	<li>Brown Syndrome</li>
	<li>Optic Nerve</li>
	<li>Congenital Nystagmus</li>
	<li>Duane Syndrome</li>
	<li>Pseudoexotropia</li>
	<li>Trochlear Nerve Palsy</li>
	<li>Intraocular Pressure</li>
	<li>Demodicosis</li>
	<li>Presbyopia</li>
	<li>Fungal Endophthalmitis</li>
	<li>Glaucoma</li>
	<li>Phakomatoses</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Giuseppe Giannaccare,Chung-Yi Chen,Anninos A. Photios ,Cristina Crenguta Albu
                    [country] => Italy,Taiwan,Greece,Romania
                    [page_url] => giuseppe-giannaccare,chung-yi-chen,anninos-a-photios,cristina-crenguta-albu
                )

            [10] => stdClass Object
                (
                    [j_id] => 9
                    [j_name] => Mathews Journal of Emergency Medicine
                    [j_url_name] => Emergency Medicine
                    [j_page_url] => emergency-medicine
                    [j_issn] => 2474-3607
                    [j_image] => mathews-journal-of-emergency-medicine2.jpg
                    [j_alttitle] => 2474-3607
                    [j_description] => <p><strong>Mathews Journal of Emergency Medicine</strong>&nbsp;is an Open Access, peer reviewed, online journal that publishes articles on all the significant parts of clinical and fundamental examination of research carried out in all aspects related to Emergency medicine.</p>

<p>Mathews Journal of Emergency Medicine publishes all papers related to advancement of the research carried out in all aspects of emergency medicine which is commonly defined as medical specialty percieved by undifferentiated and unscheduled patients with illnesses or injuries the prudent layperson, or someone on his or her behalf, as requiring immediate medical or surgical evaluation and treatment.</p>

<p>Mathews Journal of Emergency Medicine invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Emergency Medicine covers but not limited to the following</strong></p>

<p>&nbsp;</p>

<ul>
	<li>Emergency Medicine</li>
	<li>Cardiac Arrest</li>
	<li>Head Injury</li>
	<li>Abdominal Pain</li>
	<li>Critical Care</li>
	<li>Physical Examination</li>
	<li>Cervical Spine</li>
	<li>Deep Venous Thrombosis</li>
	<li>Respiratory Rate</li>
	<li>ED quality management</li>
	<li>Geriatric emergency medicine</li>
	<li>Alcohol-Related Emergencies</li>
	<li>Emergency Radiology</li>
	<li>Chest Pain</li>
	<li>Internal Medicine</li>
	<li>Osteopathic Emergency</li>
	<li>Thrombocytopenia</li>
	<li>Wound Management</li>
	<li>Geriatric Neurologic Emergencies</li>
	<li>Geriatric Cardiovascular Emergencies</li>
	<li>Intensive Care Unit</li>
	<li>Patient Care</li>
	<li>Traumatic Brain Injury</li>
	<li>Mechanical Ventilation</li>
	<li>Congestive Heart Failure</li>
	<li>Mortality Rate</li>
	<li>Septic Shock</li>
	<li>Subarachnoid Hemorrhage</li>
	<li>Acute Appendicitis</li>
	<li>Sexual Assault</li>
	<li>Acute Stroke</li>
	<li>Hemorrhagic Shock</li>
	<li>Sudden Death</li>
	<li>Medical Error</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Dr. Alan Lucerna ,Dr. James A Espinosa,Dr. Russell Mordecai ,Dr. Florian Lüders,Dr. Sorin Buga 
                    [country] => USA ,USA ,USA ,Germany ,California
                    [page_url] => dr-alan-lucerna,dr-james-a-espinosa,dr-russell-mordecai,dr-florian-l-ders,dr-sorin-buga
                )

            [11] => stdClass Object
                (
                    [j_id] => 16
                    [j_name] => Mathews Journal of Cardiology
                    [j_url_name] => Cardiology
                    [j_page_url] => cardiology
                    [j_issn] => 2572-6420
                    [j_image] => mathews-journal-of-cardiology1.jpg
                    [j_alttitle] => 2572-6420
                    [j_description] => <p><strong>Mathews Journal of Cardiology</strong>&nbsp;is global, peer reviewed, open-access online journal distributed the most recent discoveries in cardiology research. It declared exploratory, restorative examination on assortment subjects of cardiology.</p>

<p>Mathews Journal of Cardiology expects to publish most elevated quality material covering clinical, investigative and medicinal articles. Our journal is a freely accessed that publishes original articles on clinical way to deal with the determination and treatment of cardiovascular infection and diseases.</p>

<p>Mathews Journal of Cardiology invites Research articles, Review articles, Short Reviews, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Congenital heart disease</li>
	<li>Coronary stent</li>
	<li>Aneurysm</li>
	<li>Angioplasty</li>
	<li>Arrhythmias</li>
	<li>Atherosclerosis</li>
	<li>Cardiac Evolution</li>
	<li>Coronary artery diseases</li>
	<li>Cardiovascular biology</li>
	<li>Hemofiltration</li>
	<li>Hemodialysis</li>
	<li>Blood Transfusion</li>
	<li>Electrocardiography</li>
	<li>Embolism</li>
	<li>Endocarditis</li>
	<li>Myocardial ischemia</li>
	<li>Pericarditis</li>
	<li>Pericardium</li>
	<li>Cardiac Anesthesia</li>
	<li>Cardiovascular gene therapy</li>
	<li>Cardiac development</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Bai-Yan Li ,Nikolai Zhelev,FR Breijo Marquez,Maurizio Santomauro
                    [country] => China,UK,USA,Italy
                    [page_url] => bai-yan-li,nikolai-zhelev,fr-breijo-marquez,maurizio-santomauro
                )

            [12] => stdClass Object
                (
                    [j_id] => 15
                    [j_name] => Mathews Journal of Gastroenterology & Hepatology
                    [j_url_name] => Gastroenterology Hepatology
                    [j_page_url] => gastroenterology-hepatology
                    [j_issn] => 2572-6471
                    [j_image] => mathews-journal-of-gastroenterology-hepatology1.jpg
                    [j_alttitle] => 2572-6471
                    [j_description] => <p><strong>Mathews Journal of Gastroenterology and Hepatology</strong>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which focuses on the studies related to the digestive system and its disorders.</p>

<p>Mathews Journal of Gastroenterologyand hepatology publishes papers on all ranges of cutting edge research conveyed in its field. The journal spotlights on the diseases affecting the gastrointestinal tract, which include the organs from mouth to anus. Aside from this it covers development and specialized advances on different methodologies for the treatment of digestive system related diseases.</p>

<p>Mathews Journal of Gastroenterology&amp; Hepatology invites Research articles, Review articles, Short Reviews, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Inflammatory Bowel Disease</li>
	<li>Ulcerative Colitis</li>
	<li>Colorectal Cancer</li>
	<li>Irritable Bowel Syndrome</li>
	<li>Intestinal Epithelial Cell</li>
	<li>Liver Transplantation</li>
	<li>Ultrasonography</li>
	<li>Hepatocellular Carcinoma</li>
	<li>Kupffercell</li>
	<li>Partial Hepatectomy</li>
	<li>Hepatic Encephalopathy</li>
	<li>Acute Liver Failure</li>
	<li>Hepatic Fibrosis</li>
	<li>Viral Hepatitis</li>
	<li>Lipopolysaccharide</li>
	<li>Therapeutic Advances in Gastroenterology</li>
	<li>Neurogastroenterology and Motility</li>
	<li>Gastrointestinal and Liver Diseases</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Dr. Mikio Zeniya,Dr. Aziz Koleilat,Dr. Kahraman Alisan,Dr. Alexander Birbrair
                    [country] => Japan,Beirut, Lebanon,Essen, Germany,Brazil
                    [page_url] => dr-mikio-zeniya,dr-aziz-koleilat,dr-kahraman-alisan,dr-alexander-birbrair
                )

            [13] => stdClass Object
                (
                    [j_id] => 24
                    [j_name] => Mathews Journal of Immunology & Allergy
                    [j_url_name] => Immunology Allergy
                    [j_page_url] => immunology-allergy
                    [j_issn] => 2575-9523
                    [j_image] => mathews-journal-of-immunology-allergy1.jpg
                    [j_alttitle] => 2575-9523
                    [j_description] => <p><strong>Mathews Journal of Immunology &amp; Allergy</strong>&nbsp;is an international, peer reviewed open access journal which distributes potential papers on all aspects of immune system in all organisms.</p>

<p>The extent of the journal envelops the complete study, which incorporates indications, causes, pathophysiology, conclusion, treatment and anticipation of allergy and the investigation of new strategies in the field of immunologic examination. It covers fundamental and clinical exploration territories including the study of immune systems.</p>

<p>Mathews Journal of Immunology &amp; Allergy invites Research articles, Review articles, Short Communications, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>
	<ul>
		<li>Monoclonal Antibody</li>
		<li>Immune System</li>
		<li>Dendritic Cell</li>
		<li>Immunoglobulin</li>
		<li>Lipopolysaccharide</li>
		<li>Epithelial Cell</li>
		<li>Inflammatory Response</li>
		<li>Innate Immunity</li>
		<li>Antibody Response</li>
		<li>Allergic Rhinitis</li>
		<li>Skin Prick Test</li>
		<li>Atopic Dermatitis</li>
		<li>Polymorphism</li>
		<li>Hypersensitive Reaction</li>
		<li>Serotonin</li>
		<li>Immune Response</li>
		<li>T Lymphocyte</li>
		<li>Adaptive Immunity</li>
		<li>Signalling Pathway</li>
		<li>Infectious Disease</li>
	</ul>
	</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Andrey A. Zamyatnin,Sergey Sennikov ,Salvatore Sutti
                    [country] => Russia,Russia,Italy
                    [page_url] => andrey-a-zamyatnin,sergey-sennikov,salvatore-sutti
                )

            [14] => stdClass Object
                (
                    [j_id] => 8
                    [j_name] => Mathews Journal of Dermatology
                    [j_url_name] => Dermatology
                    [j_page_url] => dermatology
                    [j_issn] => 2474-6894
                    [j_image] => mathews-journal-of-dermatology1.jpg
                    [j_alttitle] => 2474-6894
                    [j_description] => <p><strong>Mathews Journal of Dermatology</strong>&nbsp;ia an Open Access, peer reviewed, globally online distributed journal, which shares original papers on all the related territories of cutting edge research carried out in dermatology and its related research field.</p>

<p>Mathews Journal of Dermatology concentrate on distributed data concerning the structure and capacity of skin and counteractive action, finding and treatment of skin ailments. The journal gives novel data of clinical and major angles also additionally inquires about the fundamental ramifications in the dermatology and skin diseases.</p>

<p>Mathews Journal of Dermatology invites Research articles, Review articles, Short Reviews, Case reports, opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Skin Cancer</li>
	<li>Bacterial skin diseases</li>
	<li>Dermal fungal infections</li>
	<li>Dermatopathology</li>
	<li>Pigmentation disorders</li>
	<li>Contact dermatitis</li>
	<li>Atopic dermatitis</li>
	<li>Phytophotodermatitis</li>
	<li>Cosmetic Dermatology</li>
	<li>Mohs surgery</li>
	<li>Pediatric Dermatology</li>
	<li>Teledermatology</li>
	<li>Plastic surgery</li>
	<li>Psychodermatology</li>
	<li>Dermatosurgery and cutaneous laser therapy</li>
	<li>Wound repair and Burn treatment</li>
	<li>Epidemiology of skin diseases</li>
	<li>Skin grafting and immune response</li>
	<li>Sexually transmitted diseases</li>
	<li>Diagnostic methods and tests</li>
	<li>Pharmacology and therapy</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Dr. Gabriel Wittum ,Dr. Michael R Hamblin ,Dr. Razvigor Darlenski ,Dr. Theognosia Vergou 
                    [country] => Germany,USA ,Bulgaria,Greece 
                    [page_url] => dr-gabriel-wittum,dr-michael-r-hamblin,dr-razvigor-darlenski,dr-theognosia-vergou
                )

            [15] => stdClass Object
                (
                    [j_id] => 11
                    [j_name] => Mathews Journal of Diabetes & Obesity
                    [j_url_name] => Diabetes Obesity
                    [j_page_url] => diabetes-obesity
                    [j_issn] => 2572-6447
                    [j_image] => mathews-journal-of-diabetes-obesity1.jpg
                    [j_alttitle] => 2572-6447
                    [j_description] => <p><strong>Mathews Journal of Diabetes &amp; Obesity&nbsp;</strong>is an international, peer reviewed Open Access journal which distributes potential papers on metabolism and diverse sorts of Diabetes &amp; Obesity and its clinical research. The extent of the journal envelops the complete study, which incorporates indications, causes, pathophysiology, conclusion, treatment and anticipation of diabetes and the investigation of new strategies in the field of diabetic examination like organ transplantation, tissue recovery and remedial developments of diabetes and obesity. The extension additionally incorporates the clinical investigation of all the metabolic pathways that happen in all the living beings. Mathews Journal of Diabetes &amp; Obesity invites Research articles, Review articles, Short Communications, Reviews articles, Case reports, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Body mass index</li>
	<li>Abdominal fat</li>
	<li>Central obesity</li>
	<li>Insulin resistance syndrome</li>
	<li>Insulin therapy</li>
	<li>Islet transplantation</li>
	<li>Islets of langerhans</li>
	<li>Non-insulin dependent diabetes mellitus</li>
	<li>Renal failure and impotence</li>
	<li>Type 1 diabetes</li>
	<li>Type 2 diabetes</li>
	<li>Coronary heart disease</li>
	<li>Diabetes mellitus</li>
	<li>Diet induced obese</li>
	<li>Diabetic nephropathy</li>
	<li>Diabetic neuropathy</li>
	<li>Diabetic retinopathy</li>
	<li>Fasting insulin</li>
	<li>Gastrointestinal disorders</li>
	<li>Gestational diabetes</li>
	<li>Glomerular filtration rate</li>
	<li>Glucose tolerance test</li>
	<li>Glucose transport</li>
	<li>Hypertension and hyperlipidemia</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Yoshifumi Saisho ,SubrataChakrabarti ,Anna Maria Giudetti 
                    [country] => Japan,Canada,Italy
                    [page_url] => yoshifumi-saisho,subratachakrabarti,anna-maria-giudetti
                )

            [16] => stdClass Object
                (
                    [j_id] => 14
                    [j_name] => Mathews Journal of Urology and Nephrology
                    [j_url_name] => Urology Nephrology
                    [j_page_url] => urology-nephrology
                    [j_issn] => 2577-1396
                    [j_image] => mathews-journal-of-urology-and-nephrology1.jpg
                    [j_alttitle] => 2577-1396
                    [j_description] => <p><strong>Mathews Journal of Urology and Nephrology</strong>&nbsp;is a peer reviewed-open access journal. Its main aim is the development of scientific community internationally by publishing world class articles related to Uro-radiology, research and clinical investigation of nephrology, Genito-urinary medicine, kidney&rsquo;s functions, Andrology. The articles accepted in Journal of urology and Nephrology support journal&rsquo;s goals to associate clinical physicians with the researchers. These articles highlight new discoveries and research that are majorly going in the field of&nbsp;Urology and Nephrology.</p>

<p>The Journal of Urology and Nephrology covers the wide scope including: Pediatric urology, clinical nephrology, urologic oncology (cancer), renal transplantation, renal replacement therapy, male infertility, calculi (urinary tract stones), female urology, neurourology (voiding disorders, urodynamic evaluation of patients and erectile dysfunction or impotence), Oncology, Endourology.</p>

<p>Mathews Journal of Urology and Nephrology invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Urology and Nephrology covers but not limited to the following</strong></p>

<ul>
	<li>Paediatric urology</li>
	<li>Uro-radiology</li>
	<li>Nephrostomy</li>
	<li>Nephrotoxins</li>
	<li>Peritoneal dialysis</li>
	<li>Uro-oncology</li>
	<li>Genito-urinary medicine</li>
	<li>NeurourologyM</li>
	<li>Urologic Reconstruction</li>
	<li>Urologic Trauma</li>
	<li>Infertility</li>
	<li>Andrology</li>
	<li>Impotence</li>
	<li>Female Urology</li>
	<li>Epidemiology</li>
	<li>Urologic Transplant</li>
	<li>Infectious Diseases in Urology</li>
	<li>Transexual surgery</li>
	<li>Adrenal gland</li>
	<li>Vasculitis</li>
	<li>Angiotensin</li>
	<li>Kidney Abnormalities</li>
	<li>Pyelonephritis</li>
	<li>Acute Tubular Necrosis</li>
	<li>Clinical Dialysis</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Dr. William-L-Nyhan,Dr. Yi Shi,Dr. Costas Fourtounas,Dr. Evan T. Keller
                    [country] => USA,China,Larissa Greece,U.S.A
                    [page_url] => dr-william-l-nyhan,dr-yi-shi,dr-costas-fourtounas,dr-evan-t-keller
                )

            [17] => stdClass Object
                (
                    [j_id] => 23
                    [j_name] => Mathews Journal of Surgery
                    [j_url_name] => Surgery
                    [j_page_url] => surgery
                    [j_issn] => 2575-9531
                    [j_image] => mathews-journal-of-surgery1.jpg
                    [j_alttitle] => 2575-9531
                    [j_description] => <p><strong>Mathews Journal of Surgery</strong>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which focuses on the studies related to the medical care and treatment of injuries or disorders of the body by incision.</p>

<p>Mathews Journal of Surgery publishes papers on all ranges of cutting edge research conveyed in its field. The Journal spotlights on different types of surgeries i.e. pediatric, reconstructive, refractory, gastrointestinal, digestive, head &amp; neck, foot &amp; ankle, musculoskeletal, plastic, etc. It also covers pathology and advancements in surgery.</p>

<p>Mathews Journal of Surgery invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Pediatric Surgery</li>
	<li>Surgical Pathology</li>
	<li>Thoracic and Cardiovascular Surgery</li>
	<li>Shoulder and Elbow Surgery</li>
	<li>Reconstructive Surgery</li>
	<li>Refractive Surgery</li>
	<li>Vascular Surgery</li>
	<li>Neurosurgery</li>
	<li>Surgical Endoscopy</li>
	<li>Gastrointestinal Surgery</li>
	<li>Digestive Surgery</li>
	<li>Head and Neck Surgery</li>
	<li>Oral and Maxillofacial Surgery</li>
	<li>Foot and Ankle Surgery</li>
	<li>Surgical Infections</li>
	<li>Musculoskeletal Surgery</li>
	<li>Plastic Surgery</li>
	<li>Endovascular Therapy</li>
	<li>Vascular Surgery</li>
	<li>Emergency Surgery</li>
	<li>Craniofacial Surgery</li>
	<li>Colon and Rectal Surgery</li>
	<li>Gynaecological Surgery</li>
	<li>Ambulatory Surgery</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] =>  Roberto de la Plaza Llamas, Igor Klepikov,Jose Dario, Juan Bellido Luque
                    [country] => Spain,Russia,Granada, Spain,Seville, Spain
                    [page_url] => roberto-de-la-plaza-llamas,igor-klepikov,jose-dario,juan-bellido-luque
                )

            [18] => stdClass Object
                (
                    [j_id] => 22
                    [j_name] => Mathews Journal of Pharmaceutical Science
                    [j_url_name] => Pharmaceutical science
                    [j_page_url] => pharmaceutical-science
                    [j_issn] => 2474-753X
                    [j_image] => mathews-journal-of-pharmaceutical-science1.jpg
                    [j_alttitle] => 2474-753X
                    [j_description] => <p><strong>Mathews Journal of Pharmaceutical Science</strong>&nbsp;is an open accessed, peer-reviewed, international journal which publishes papers related to the design, action, delivery, and disposition of drugs.</p>

<p>Mathews Journal of Pharmaceutical Science expects to distribute most elevated quality material covering a wide range of aspects including Drug Discovery and Design, Drug Delivery, Drug Action, Clinical Sciences, Regulatory Affairs, etc.</p>

<p>Mathews Journal of Pharmaceutical Science invites Research articles, Review articles, Short Communications, Case reports, Editorials, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>
	<ul>
		<li>Controlled Release</li>
		<li>Molecular Pharmaceutics</li>
		<li>Biopharmaceutics</li>
		<li>Drug Delivery</li>
		<li>Pharmaceutical Sciences</li>
		<li>Medicinal Chemistry</li>
		<li>Pharmaceutical Biotechnology</li>
		<li>Pharmacokinetics</li>
		<li>Therapeutic Agents</li>
		<li>Drug Disposition</li>
		<li>Administrative Pharmacy</li>
		<li>Pharmacy Practice</li>
		<li>Microencapsulation</li>
		<li>Pharmacognosy</li>
		<li>Cosmetic Science</li>
		<li>Drug Delivery and Formulation</li>
		<li>Medicinal Plants</li>
		<li>Nanoscience</li>
		<li>Pharmacology</li>
		<li>Applied Pharmaceutics</li>
		<li>Drug Metabolism</li>
		<li>Drug Design and Discovery</li>
		<li>Pharmaceutical Analysis</li>
		<li>Bioequivalence and Bioavailability</li>
		<li>Regulatory Affairs</li>
	</ul>
	</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] =>  Lana Gettman,Yuri Griko ,Marzanna Cechowska-Pasko, Raffaele Pilla
                    [country] => USA,USA,Poland,Italy
                    [page_url] => lana-gettman,yuri-griko,marzanna-cechowska-pasko,raffaele-pilla
                )

            [19] => stdClass Object
                (
                    [j_id] => 12
                    [j_name] => Mathews Journal of Nutrition & Dietetics
                    [j_url_name] => Nutrition
                    [j_page_url] => nutrition
                    [j_issn] => 2474-7475
                    [j_image] => mathews-journal-of-nutrition-dietetics1.jpg
                    [j_alttitle] => 2474-7475
                    [j_description] => <p><strong>Mathews Journal of Nutrition &amp; Dietetics</strong>&nbsp;is an open access, peer reviewed, multidisciplinary journal, which focuses on the interaction of nutrients and other substances in foodin relation to maintenance, growth, reproduction, health and disease of an organism and also applying knowledge in food and nutrition to improving and maintaining good health.</p>

<p>Mathews Journal of Nutrition &amp; Dietetics publishes papers on all ranges of cutting edge research conveyed in its field. Aside from this it covers development and specialized advances in the interaction of nutrients and other substances in food.</p>

<p>Mathews Journal of Nutrition &amp; Dietetics invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Food Intake</li>
	<li>Body Mass Index</li>
	<li>Oxidant Stress</li>
	<li>Body Composition</li>
	<li>Fatty Acid</li>
	<li>Body Weight</li>
	<li>Dietary Intake</li>
	<li>Fruit and Vegetables</li>
	<li>Nutritional Status</li>
	<li>Amino Acid</li>
	<li>Weight Loss</li>
	<li>Risk Factors</li>
	<li>Energy Intake</li>
	<li>Cholesterol</li>
	<li>Dairy Products</li>
	<li>Dietetics</li>
	<li>Nutritional Biochemistry</li>
	<li>Sports Nutrition</li>
	<li>Food Science</li>
	<li>Clinical Nutrition</li>
	<li>Physical Activity</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Tim Hideaki Tanaka ,Aouatef Bellamine ,Zhongkai Zhou ,Andrey A. Zamyatnin
                    [country] => Canada,USA,China,Russia
                    [page_url] => tim-hideaki-tanaka,aouatef-bellamine,zhongkai-zhou,andrey-a-zamyatnin
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            [20] => stdClass Object
                (
                    [j_id] => 21
                    [j_name] => Mathews Journal of Anesthesia
                    [j_url_name] => Anesthesia
                    [j_page_url] => anesthesia
                    [j_issn] => 2575-9493
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_alttitle] => 2575-9493
                    [j_description] => <p><strong>Mathews Journal of Anesthesia</strong>&nbsp;supports the predictable improvement and movement in anesthesiology, torment, emergency arrangement or concentrated thought exploration bunch by extending access to partner evaluated investigative written work.</p>

<p>Mathews Journal of Anesthesia is an open access, peer reviewed journal of special articles on the practical and clinical techniques in anesthesia. Our goal is to transform into a general reference for guideline in the field for all specialists included amid the time spent scattering learning and capacities of Mathews Journal of Anesthesia.</p>

<p>Mathews Journal of Anesthesia invites Original articles, Research articles, Reviews, Case reports, Opinion articles, etc. as submissions.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>Monitoring in Anesthesia</li>
	<li>Nephrologic Surgery</li>
	<li>Neurosurgery&nbsp;&nbsp; Oncology &amp; Surgery</li>
	<li>Operative -N- Non-Operative Trauma Care</li>
	<li>Ophthalmologic Surgery</li>
	<li>Perioperative Complications</li>
	<li>Pharmacokinetics</li>
	<li>Plastic Surgery</li>
	<li>Post-Anesthesia Care Unit</li>
	<li>Postoperative Pain Management</li>
	<li>Preoperative Evaluation &amp; Anesthesia risk</li>
	<li>Reconstructive &amp; Aesthetic Surgery</li>
	<li>Regional Anesthesia &amp; Nerve Block</li>
	<li>Rheumatology &amp; Surgery</li>
	<li>Surgery in Otolaryngology</li>
	<li>Surgical Oncology</li>
	<li>Thoracic Surgery</li>
	<li>Trauma Radiology</li>
	<li>Trauma Resuscitation &amp; Hemorrhage Control</li>
	<li>Trauma Surgery</li>
	<li>Urologic Surgery</li>
	<li>Vascular Surgery</li>
	<li>Anaesthetic Issues and Peri-Operative Care</li>
	<li>Anesthesia Management</li>
	<li>Anesthetics Pharmacology</li>
	<li>Brain Death</li>
	<li>Breast Surgery</li>
	<li>Cardiopulmonary Cerebral Resuscitation</li>
	<li>Cardiovascular Surgery</li>
	<li>Colorectal Surgery</li>
	<li>Critical Care Medicine</li>
	<li>Critical/Intensive Care of Trauma Patients</li>
	<li>Dermatological Surgery</li>
	<li>Emergency Care</li>
	<li>Endocrine Surgery</li>
	<li>Ethical &amp; Legal Aspects of Anesthesia Care</li>
	<li>Fluid Therapy, Transfusion &amp; Coagulopathy</li>
	<li>Fluid, Electrolyte &amp; Acid Base Disorders</li>
	<li>Laparoscopic Surgery</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Leigh Ann Price,Michael W. Lew,Ozgur Karcioglu,John F. Bebawy
                    [country] => USA,USA,Turkey,USA
                    [page_url] => leigh-ann-price,michael-w-lew,ozgur-karcioglu,john-f-bebawy
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            [21] => stdClass Object
                (
                    [j_id] => 20
                    [j_name] => Orthopedics Research Journal
                    [j_url_name] => Orthopedics
                    [j_page_url] => orthopedics
                    [j_issn] => 2474-6959
                    [j_image] => orthopedics-research-journal.jpg
                    [j_alttitle] => 2474-6959
                    [j_description] => <p><strong>Orthopedics Research Journal&nbsp;</strong>is an international, Open Access, peer reviewed journal that expects to publish quality research papers on the cutting edge research carried on Orthopedics and Rheumatology field.</p>

<p>The scope of the journal is to underwrite the propelled flow research on analysis and treatment of rheumatic maladies, conclusion and administration of musculoskeletal parts of grown-up and pediatric orthopedic surgery and treatment connected with atomic hereditary qualities, pathophysiology and the study of disease transmission.</p>

<p>Orthopedics Research Journal invites Research articles, Review articles, Short communications, Case reports, opinion articles, etc.</p>

<p><strong>Scope of Journal</strong></p>

<ul>
	<li>Degenerative arthropathies</li>
	<li>Inflammatory arthropathies</li>
	<li>Connective tissue diseases</li>
	<li>Soft Tissue Rheumatism</li>
	<li>Diseases affecting bones</li>
	<li>Congenital and familial Disorders affecting Joints</li>
	<li>Orthopedic implants</li>
	<li>Musculoskeletal function biology&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li>
	<li>Arthroplasty/Joint Replacement</li>
	<li>Rheumatoid arthritis</li>
	<li>Osteoarthritis</li>
	<li>Epidemiology of Rheumatic diseases</li>
	<li>Foot &amp; Ankle surgery</li>
	<li>Fracture Management</li>
	<li>Muscle-Tendon &amp; Ligaments</li>
	<li>Osteoporosis</li>
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                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => XueqinGao ,Tamer A.Gheita , Jacek Kaczmarczyk,Natsis Konstantinos
                    [country] => Houston,Texas USA,Egypt,Poland,Greece
                    [page_url] => xueqingao,tamer-a-gheita,jacek-kaczmarczyk,natsis-konstantinos
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                    [j_id] => 1
                    [j_name] => Mathews Journal of Veterinary Science
                    [j_url_name] => Veterinary Science
                    [j_page_url] => veterinary-science
                    [j_issn] => 2572-6579
                    [j_image] => mathews-journal-of-veterinary-science.jpg
                    [j_alttitle] => Mathews Journal of Veterinary Science
                    [j_description] => <p><strong>Mathews Journal of Veterinary Science</strong>&nbsp;is an Open Access, peer reviewed, online journal that publishes articles on all the significant parts of clinical and fundamental examination of research carried out in non-human animals. The Journal advances studies on prevention, diagnosis and treatment of disease, disorder and injurycovering all animal species, both domesticated and wild, with a wide range of conditions which can affect different species.</p>

<p>The scope of the Journal underscores on the logical learning, inventive systems and disclosures making useful commitments to the livestock health monitoring and treatment.</p>

<p>Mathew&rsquo;s Journal of Veterinary Science Journal invites manuscripts Research articles, Reviews articles, Case reports, Editorials, Opinion articles, etc.</p>

<p><strong>Scope of the Journal</strong></p>

<ul>
	<li>
	<ul>
		<li>Animal Model</li>
		<li>Veterinary Microbiology</li>
		<li>Animal Biosciences</li>
		<li>Animal Behaviour Science</li>
		<li>Veterinary Clinical Pathology</li>
		<li>Animal Breeding and Genetics</li>
		<li>Animal Endocrinology</li>
		<li>Animal Science</li>
		<li>Animal Nutrition</li>
		<li>Veterinary Cardiology</li>
		<li>Veterinary Ophthalmology</li>
		<li>Poultry Science</li>
		<li>Veterinary Dentistry</li>
		<li>Veterinary Science and Technology</li>
		<li>Veterinary Advances</li>
		<li>Animal Medicine and Surgery</li>
		<li>Veterinary Anaesthesia</li>
		<li>Veterinary Research</li>
	</ul>
	</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Georges Chapouthier,Marko Samardzija ,Massimo Giangaspero,Stoycho Dimitrov Stoev
                    [country] => France,Croatia,Italy,Bulgaria
                    [page_url] => georges-chapouthier,marko-samardzija,massimo-giangaspero,stoycho-dimitrov-stoev
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                    [j_id] => 27
                    [j_name] => Mathews Journal of Nursing and Health Care
                    [j_url_name] => NursingCare
                    [j_page_url] => nursingcare
                    [j_issn] => 2692-8469
                    [j_image] => mathews-journal-of-nursing-and-health-care1.jpg
                    [j_alttitle] => 2572-XXXX
                    [j_description] => <p><strong>Mathews Journal of Nursing and Health Care&nbsp;</strong>is a peer reviewed-open access journal. Its main aim is the development of scientific community internationally by publishing world class articles related to Nursing and Healthcare. Journal of Nursing and Health Care brings articles in different areas related to Psychiatric and mental health nursing, Learning disability nursing, Pediatric nursing, Geriatric nursing, Home health nursing, Community and Home care, Maternity and Women&#39;s health, Social Interactions, Health habits Self-management &amp; Personal Development.</p>

<p>Journal of Nursing and Health Care covers the wide scope including: Public Health Nursing, Critical Care Nursing, Perioperative Nursing, Oncology Nursing, Midwifery, Psychiatric Nursing, Pediatric Nursing, Geriatric Nursing, Holistic Nursing, Transcultural Nursing, Forensic Nursing, Emergency Nursing, School Nursing, Hospice and Palliative Care Nursing, Military Nursing, Orthopaedic Nursing, Rehabilitation Nursing, Advanced Practice Nursing, Neuroscience Nursing, Occupational Health Nursing, Cardiovascular Nursing, Obstetric Nursing, Family Nursing, Maternal-Child Nursing, Nephrology Nursing, Rural Nursing.</p>

<p>Mathews Journal of Nursing and Health Care invites Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Nursing and Health Care covers but not limited to the following</strong></p>

<ul>
	<li>Community Health Nursing</li>
	<li>Nursing Education</li>
	<li>Pediatric Nursing Care</li>
	<li>Emergency Nursing</li>
	<li>Family Nursing</li>
	<li>Generic Medicines</li>
	<li>Geriatric nursing</li>
	<li>Psychiatric and mental health nursing</li>
	<li>Health Services</li>
	<li>Medical Practice</li>
	<li>Health Care Systems</li>
	<li>Nursing Ethics</li>
	<li>Public Health Nursing</li>
	<li>Adult Nursing</li>
	<li>Nursing and Health Care</li>
	<li>Patient Care</li>
	<li>Critical Care Nursing</li>
	<li>Nursing Theories</li>
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                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 
                    [name] => Ioannis Kyriazis,Emre Yanikkerem,Vasfiye Bayram Deger,RN Feride Taskin Yilmaz 
                    [country] => Greece,Turkey, Turkey,Turkey
                    [page_url] => ioannis-kyriazis,emre-yanikkerem,vasfiye-bayram-deger,rn-feride-taskin-yilmaz
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                    [j_id] => 26
                    [j_name] => Mathews Journal of Forensic Research
                    [j_url_name] => ForensicResearch
                    [j_page_url] => forensicresearch
                    [j_issn] => 2692-8442
                    [j_image] => mathews-journal-of-forensic-research1.jpg
                    [j_alttitle] => 2572-XXXX
                    [j_description] => <p><strong>Mathews Journal of Forensic Research:</strong>&nbsp;is an Open Access Journal that publishes vast topics of forensic discoveries which includes anatomy, pathology, and psychiatry.</p>

<p>Forensic Research focuses on the application of medical knowledge to the investigation of crime, particularly in establishing the causes of injury or death. It interprets and establishes the medical facts in civil or criminal law cases. Also called legal medicine or medical jurisprudence.</p>

<p>It is typically involved in cases concerning blood relationship, mental illness, injury, or death resulting from violence. Autopsy (post-mortem examination) is often used to determine the cause of death, particularly in cases where foul play is suspected.</p>

<p>Mathews Journal of Forensic Research invites Editorials, Research articles, Review articles, Short Communication, Case reports, Opinion articles, etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Forensic Research covers but not limited to the following</strong></p>

<ul>
	<li>Legal medicine</li>
	<li>Autopsies</li>
	<li>Forensic pathology</li>
	<li>Forensic science</li>
	<li>Forensic toxicology</li>
	<li>Marks of violence</li>
	<li>Forensic microanalysis</li>
	<li>DNA Typing</li>
	<li>Computer forensics</li>
	<li>DNA Fingerprinting</li>
	<li>Forensic Psychology</li>
	<li>Crime Scene Investigation</li>
	<li>Blood splatter analysis</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Marek Kowalczuk,Evan T. Keller,Oscar Alonso Plaza Patino,Roberto Maniglio
                    [country] => UK,U.S.A,Colombia,Rome, Italy
                    [page_url] => marek-kowalczuk,evan-t-keller,oscar-alonso-plaza-patino,roberto-maniglio
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                    [j_id] => 2
                    [j_name] => Mathews Journal of Sports Medicine
                    [j_url_name] => Sports Medicine
                    [j_page_url] => sports-medicine
                    [j_issn] => 2837-4479
                    [j_image] => mathews-journal-of-sports-medicine1.jpg
                    [j_alttitle] => SportsMedicine
                    [j_description] => <p><strong>Mathews Journal of Sports Medicine (2837-4479)&nbsp;</strong>is an Open Access, peer reviewed, on line publishing Journal. The main objective of the journal is to publish the quality research at an international level prioritizing Sports injuries and medical applications in treating them. As this Journal is a scientific and peer reviewed journal it covers high quality manuscripts which are both relevant and applicable to the broad field of Medicine in sports.</p>

<p>The journal aims to collect and maintain the precise data in the fields of Exercise physiology, Physiotherapy, Clinical Sports Medicine etc. The journal expands its horizon to bring into light and to disseminate the outstanding research and development results to the world instantaneously by the latest advances in the domain of Sports Injuries &amp; Medicine</p>

<p>Mathews Journal of Sports Medicine invites Research Papers, Review Articles, Short Communications, Case Reports, Mini-Reviews, Opinions, Letter to Editors, etc.</p>

<p><strong>Scope of Mathews Journal of Sports Medicine covers but not limited to the following</strong></p>

<ul>
	<li>Sport MedicineSport Nutrition</li>
	<li>Sports Management</li>
	<li>Sport Performance Enhancement</li>
	<li>Sport Psychology</li>
	<li>Sports and Exercise Medicine</li>
	<li>Sports Medicine</li>
	<li>Sports Medicine and Fitness</li>
	<li>Sports Medicine Blogs</li>
	<li>Sports Medicine Case Reports</li>
	<li>Sports Medicine Nurse Practitioner</li>
	<li>Sports Medicine Practice</li>
	<li>Sports Medicine Rehabilitation</li>
	<li>Sports Psychology</li>
	<li>Sports Therapy</li>
	<li>Sports Medicine</li>
	<li>Sports Nutrition Suppliments</li>
	<li>Aerodynamics</li>
	<li>Common Sports Injuries</li>
	<li>Exercise Physiology</li>
	<li>Neurophysiology</li>
	<li>Orthopedic Surgery</li>
	<li>Pain Mechanisms</li>
	<li>Pediatric Sports Medicine</li>
	<li>Primary Care Sports Medicine</li>
	<li>Aminoacid Suppliments</li>
	<li>Bodybuilding Nutrition</li>
	<li>Pain Mechanisms Sports Podiatry</li>
	<li>Physical Activity</li>
	<li>Sports HealthSports Orthopedics</li>
	<li>Sports Injury</li>
	<li>Rehabilitation</li>
	<li>Vitamin Supplement</li>
	<li>Sports Nutrition</li>
	<li>Health and Exercise Science</li>
	<li>Dietary Supplementation</li>
	<li>Pain Mechanisms</li>
	<li>Pediatric Sports Medicine</li>
	<li>Sports Biomechanics</li>
	<li>Exercise Physiology</li>
	<li>Neurophysiology</li>
	<li>Orthopedic Surgery and Sports Medicine</li>
	<li>Athletic Physiology</li>
	<li>Sports Physiotherapy</li>
	<li>Clinical Sports Medicine</li>
	<li>Sports Doping</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] => Daniel Puciato,Elisabetta M. Zanetti ,Hamid Arazi ,Natsis Konstantinos
                    [country] => Poland,Italy,Rasht, Iran,Greece
                    [page_url] => daniel-puciato,elisabetta-m-zanetti,hamid-arazi,natsis-konstantinos
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                    [j_id] => 25
                    [j_name] => Mathews Journal of Otolaryngology
                    [j_url_name] => Otolaryngology
                    [j_page_url] => otolaryngology
                    [j_issn] => 
                    [j_image] => mathews-journal-of-otolaryngology1.jpg
                    [j_alttitle] => 2572-XXXX
                    [j_description] => <p><strong>Mathews Journal of Otolaryngology</strong>&nbsp;is a surgical subspecialty within medicine that deals with conditions of the ear, nose, and throat (ENT) and related structures of the head and neck.It focuses mainly on topics of Rhinology, sinusitis, rhinitis, hearing loss,Neurology, otology, tonsillectomy, vocology, laryngitis, etc.</p>

<p>Mathews Journal of Otolaryngology invites Editorials, Research articles, Review articles, Short Reviews, Short communications, Case reports, Opinion articles, Image articles etc. as entries.</p>

<p><strong>Scope of Mathews Journal of Otolaryngology covers but not limited to the following</strong></p>

<ul>
	<li>Otology</li>
	<li>Neurology</li>
	<li>Sinus</li>
	<li>Larynx</li>
	<li>Laryngology</li>
	<li>Otitis media</li>
	<li>Ear surgery</li>
	<li>Eardrum</li>
	<li>Cleft lip</li>
	<li>Cleft palate</li>
	<li>Temporal bone</li>
	<li>Ear noise</li>
	<li>Polyps</li>
	<li>Face lift</li>
	<li>Tonsil</li>
	<li>Sore throat</li>
</ul>

                    [j_email] => contact@eopenjournals.com
                    [j_tollfree] => 
                    [j_pub_dt] => 13-10-2020
                    [name] =>  Alfio Ferlito ,Raja Kummoona,Vural Fidan ,Jurek olszewski
                    [country] => Italy,London,Turkey,Poland
                    [page_url] => alfio-ferlito,raja-kummoona,vural-fidan,jurek-olszewski
                )

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    [journal_iddd] => 21
    [journal_name] => Mathews Journal of Anesthesia
    [j_url_name] => Anesthesia
    [j_image] => mathews-journal-of-anesthesia1.jpg
    [j_page_url] => anesthesia
    [issn] => 2575-9493
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                            [issue] => Volume 4, Issue 1
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                            [issue] => Volume 3, Issue 1
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                            [issue] => Volume 1, Issue 1
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                    [fixed_date] => 2024-11-07
                    [id] => 1091
                    [title] => Suxamethonium- Induced Prolonged Apnea: Insights from a Clinical Case
                    [type] => Case Report
                    [page_url] => suxamethonium-induced-prolonged-apnea-insights-from-a-clinical-case
                    [vol_id] => 191
                    [issue_id] => 306
                    [image] => suxamethonium-induced-prolonged-apnea-insights-from-a-clinical-case.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Yaaqoob Alhammadi<sup>1,</sup>*, Girishkumar Modi<sup>2</sup></strong></p>

                    [about] => <p>Alhammadi Y, et al. (2024). Suxamethonium- Induced Prolonged Apnea: Insights from a Clinical Case. Mathews J Anesth. 5(1):16.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p><sup>1</sup>Aesthesiologist and Intensivist, STMC Hospital / Tawam Hospital, UAE</p>

<p><sup>2</sup>Specialist Anesthesiologist, STMC Hospital / Tawam Hospital, UAE</p>

<p><strong>*Corresponding author: </strong>Dr. Yaaqoob Alhammadi, MD, MHA, PhD, STMC Hospital / Tawam Hospital, Al ain, UAE, Email: <a href="mailto:alhammadi@gmx.com">alhammadi@gmx.com</a></p>

<p><strong>Received Date:</strong> October 08, 2024</p>

<p><strong>Published Date:</strong> November 07, 2024</p>

<p><strong>Citation:</strong> Alhammadi Y, et al. (2024). Suxamethonium- Induced Prolonged Apnea: Insights from a Clinical Case. Mathews J Anesth. 5(1):16.</p>

<p><strong>Copyrights:</strong> Alhammadi Y, et al. &copy; (2024).</p>

<p><strong>ABSTRACT</strong></p>

<p>Suxamethonium, or succinylcholine, is a depolarizing neuromuscular blocker used for rapid sequence intubation in anesthesia. It acts quickly, causing temporary paralysis, but in some individuals, a deficiency or abnormality in the enzyme pseudocholinesterase (also called butyrylcholinesterase) can result in prolonged paralysis, a condition known as suxamethonium apnea.</p>

<p>Pseudocholinesterase deficiency can be inherited or acquired, and patients with this condition cannot efficiently metabolize suxamethonium, leading to delayed recovery from muscle paralysis. The clinical presentation typically includes prolonged apnea and muscle weakness long after the expected recovery time, often requiring mechanical ventilation until the effects of the drug wear off.</p>

<p><strong>Keywords: </strong>Suxamethonium Apnea, Pseudocholinesterase Deficiency, Butyrylcholinesterase (BCHE), BCHE Gene Mutation, Neuromuscular Blockade, Genetic Variability, Dibucaine Number, Fresh Frozen Plasma (FFP), Neuromuscular Monitoring, Anesthesia Complications, Genetic Testing.</p>

                    [full_text] => <p><sup>1</sup>Aesthesiologist and Intensivist, STMC Hospital / Tawam Hospital, UAE</p>

<p><sup>2</sup>Specialist Anesthesiologist, STMC Hospital / Tawam Hospital, UAE</p>

<p><strong>*Corresponding author: </strong>Dr. Yaaqoob Alhammadi, MD, MHA, PhD, STMC Hospital / Tawam Hospital, Al ain, UAE, Email: <a href="mailto:alhammadi@gmx.com">alhammadi@gmx.com</a></p>

<p><strong>Received Date:</strong> October 08, 2024</p>

<p><strong>Published Date:</strong> November 07, 2024</p>

<p><strong>Citation:</strong> Alhammadi Y, et al. (2024). Suxamethonium- Induced Prolonged Apnea: Insights from a Clinical Case. Mathews J Anesth. 5(1):16.</p>

<p><strong>Copyrights:</strong> Alhammadi Y, et al. &copy; (2024).</p>

<p><strong>ABSTRACT</strong></p>

<p>Suxamethonium, or succinylcholine, is a depolarizing neuromuscular blocker used for rapid sequence intubation in anesthesia. It acts quickly, causing temporary paralysis, but in some individuals, a deficiency or abnormality in the enzyme pseudocholinesterase (also called butyrylcholinesterase) can result in prolonged paralysis, a condition known as suxamethonium apnea.</p>

<p>Pseudocholinesterase deficiency can be inherited or acquired, and patients with this condition cannot efficiently metabolize suxamethonium, leading to delayed recovery from muscle paralysis. The clinical presentation typically includes prolonged apnea and muscle weakness long after the expected recovery time, often requiring mechanical ventilation until the effects of the drug wear off.</p>

<p><strong>Keywords: </strong>Suxamethonium Apnea, Pseudocholinesterase Deficiency, Butyrylcholinesterase (BCHE), BCHE Gene Mutation, Neuromuscular Blockade, Genetic Variability, Dibucaine Number, Fresh Frozen Plasma (FFP), Neuromuscular Monitoring, Anesthesia Complications, Genetic Testing.</p>

<p><strong>GENETIC VARIABILITY</strong></p>

<p>The genetic variability of pseudocholinesterase (BCHE) activity, which affects suxamethonium as well as mivacurium metabolism, is due to different mutations in the BCHE gene [1-3]. The frequencies of different variants of this gene vary across populations. Here&#39;s an estimate of the percentages of variability seen in people with respect to suxamethonium sensitivity:</p>

<ol>
	<li>Normal Homozygous Individuals (Normal Metabolism):</li>
</ol>

<p>- About 96% of the population has normal pseudocholinesterase activity and experiences typical muscle relaxation and recovery after suxamethonium administration.</p>

<ol>
	<li>Heterozygous Individuals (Mild Deficiency):</li>
</ol>

<p>- Around 3-4% of the population carries one normal allele and one abnormal allele for pseudocholinesterase. These individuals may experience slightly prolonged paralysis after suxamethonium administration, but it is usually not clinically significant [4].</p>

<ol>
	<li>Homozygous Atypical Individuals (Severe Deficiency):</li>
</ol>

<p>- Approximately 1 in 2,500 to 1 in 3,000 individuals (or about 0.03-0.04% of the population) are homozygous for an abnormal pseudocholinesterase gene, leading to severe enzyme deficiency and prolonged paralysis (lasting hours) after suxamethonium administration [5].</p>

<p>Genetic Variants:</p>

<p>There are different mutations of the BCHE gene, and their distribution may vary by ethnicity:</p>

<p>- Atypical Variant (A allele): This variant is common in Caucasian populations, with a carrier frequency of around 4-5%</p>

<p>- Kalow Variant (K allele): Seen in about 1-2% of certain populations.</p>

<p>- Other rare variants: Some populations have other rare mutations that may affect pseudocholinesterase activity, such as the fluoride-resistant (F) 0.03-0.04 % and silent (S) variants 0.02-0.04 % in general population [6].</p>

<p>These percentages highlight the broad range of genetic variability in the population that can affect an individual&rsquo;s response to suxamethonium.</p>

<p><strong>DIAGNOSTIC INVESTIGATIONS</strong></p>

<p>When suxamethonium apnea is suspected, the following laboratory and diagnostic tests can help confirm the diagnosis:</p>

<ol>
	<li>Pseudocholinesterase Activity Test:</li>
</ol>

<p>- This test measures the activity level of pseudocholinesterase in the blood. A decreased level of this enzyme indicates a deficiency and confirms the diagnosis of suxamethonium apnea.</p>

<p>- Normal levels: 3,200&ndash;6,500 U/L.</p>

<p>- Decreased levels: Usually &lt; 3,200 U/L in cases of deficiency.</p>

<ol>
	<li>Dibucaine Number:</li>
</ol>

<p>- The dibucaine number indicates how well the enzyme pseudocholinesterase is functioning. Dibucaine is a local anesthetic that inhibits normal pseudocholinesterase, but it does not affect abnormal forms of the enzyme.</p>

<p>- A normal dibucaine number is typically between 80-85. A lower number (20-30) suggests an atypical or abnormal pseudocholinesterase variant, leading to prolonged paralysis [7].</p>

<ol>
	<li>Genetic Testing:</li>
</ol>

<p>&nbsp;- In cases of inherited pseudocholinesterase deficiency, genetic testing can identify mutations in the BCHE gene responsible for producing pseudocholinesterase. This test is important for identifying family members at risk for the condition [8].</p>

<ol>
	<li>Nerve Stimulation Test:</li>
</ol>

<p>- During recovery from anesthesia, a peripheral nerve stimulator can assess the return of neuromuscular function. In patients with suxamethonium apnea, there is minimal or absent response to nerve stimulation due to the persistent neuromuscular blockade.</p>

<p><strong>TREATMENT OF SUXAMETHONIUM APNEA </strong></p>

<p>The management of suxamethonium apnea focuses on supportive care until muscle function returns. Since there is no specific antidote for suxamethonium, treatment is aimed at maintaining respiratory and cardiovascular stability during the period of paralysis. Key treatment strategies include:</p>

<ol>
	<li>Mechanical Ventilation:</li>
</ol>

<p>- Patients with suxamethonium apnea may require mechanical ventilation due to prolonged paralysis and apnea. Mechanical ventilation should continue until the patient&rsquo;s spontaneous breathing returns [9].</p>

<ol>
	<li>Fresh Frozen Plasma (FFP):</li>
</ol>

<p>- FFP contains pseudocholinesterase and can be administered to accelerate the breakdown of suxamethonium. In this case, the child received 250 ml of FFP, which led to a significant improvement in muscle strength and recovery [9].</p>

<p>- Dose: 10-20 ml/kg, depending on the severity of the enzyme deficiency and clinical condition.</p>

<ol>
	<li>Commercial Serumcholinesterase [10].</li>
</ol>

<p>Termination with commercial serum cholinesterase involves administering exogenous (commercially produced) human serum cholinesterase as a treatment to reverse suxamethonium-induced prolonged paralysis.</p>

<p>Mechanism of Action:</p>

<ol>
	<li>Suxamethonium Breakdown: Commercial serum cholinesterase is administered intravenously to provide functional enzyme that can break down suxamethonium in the bloodstream.</li>
	<li>Restoration of Muscle Function: By accelerating the metabolism of suxamethonium, the exogenous cholinesterase can terminate the prolonged apnea, allowing the patient&rsquo;s muscle function, including respiratory muscles, to recover more quickly.</li>
	<li>Shortened Paralysis Duration: This approach shortens the duration of paralysis and reduces the risk of complications associated with prolonged mechanical ventilation.</li>
</ol>

<p>Commercial serum cholinesterase is not often available, and until the effects of suxamethonium wear off, supportive care including mechanical ventilation is typically utilized. However, the injection of exogenous cholinesterase can be life-saving in emergency instances where prolonged paralysis offers additional hazards.</p>

<p>Supporting Care:</p>

<p>- If commercial cholinesterase is unavailable, patients are typically supported with mechanical ventilation until spontaneous breathing resumes, which may take several hours.</p>

<p>- The use of neuromuscular monitoring (train of four ratio) is crucial in identifying and managing prolonged paralysis due to pseudocholinesterase deficiency.</p>

<ol>
	<li>General Supportive Care:</li>
</ol>

<p>- Continuous monitoring of vital signs, particularly respiratory function, is essential. Blood gas analysis should be performed to assess for hypoxia or hypercapnia, and ventilation should be adjusted accordingly.</p>

<p>- In cases where mechanical ventilation is necessary for an extended period, transfer to an intensive care unit (ICU) is advised. It is crucial to emphasize the importance of using sedation with short-acting medication such as propofol to prevent awareness, which is very common in these situations. Awareness can occur because anesthetists often focus on monitoring for any motor or respiratory activity as a sign of patient recovery.</p>

<ol>
	<li>Reversal of Co-administered Sedatives/Opioids:</li>
</ol>

<p>- Opioid reversal with naloxone may be considered if there is a suspicion of opioid-induced respiratory depression, although this may not significantly affect suxamethonium-induced apnea.</p>

<ol>
	<li>Monitoring and Follow-up:</li>
</ol>

<p>- Following recovery from the acute episode, patients should be advised to avoid suxamethonium in future anesthetics. It is often recommended that they wear a medical alert bracelet or carry a card indicating pseudocholinesterase deficiency. Family members should also be informed of the condition to help prevent its occurrence in them, as pseudocholinesterase deficiency can be hereditary.</p>

<p><strong>CASE REPORT</strong></p>

<p><strong>Patient Background</strong></p>

<p>A 12-year-old male child, weighing 51 kg, presented for cystoscopy and ureteric JJ stenting. He was classified as ASA III due to congenital kidney and urinary tract anomalies (horseshoe kidney) and a history of multi-organ injury following a motor vehicle accident in 2020. The child required pediatric intensive care unit (PICU) admission at that time.</p>

<p><strong>Preoperative and Intraoperative Course</strong></p>

<p>The child was cleared for general anesthesia as a Class III emergency case. His preoperative blood results were acceptable range. He also has a history of multiple general anesthetic procedures in the past but has never received suxamethonium.</p>

<p>After preoxygenation, anesthesia was induced with propofol 120 mg and fentanyl 75 mcg. During induction, the patient developed laryngospasm, which made mask ventilation difficult and led to a drop in SpO2 to 70%. The patient received 40 mg IV suxamethonium, which resolved the bronchospasm promptly, restoring SpO2 to 99%. Ventilation was managed with a size 3 LMA during surgery, and the patient&rsquo;s vitals stabilized for the rest of the procedure.</p>

<p><strong>Postoperative Complication: Prolonged Apnea</strong></p>

<p>Postoperatively, the child&rsquo;s recovery from anesthesia was notably delayed, lasting up to 2.5 hours, with no spontaneous respiratory effort observed. Naloxone was administered to reverse the effects of fentanyl, but respiratory effort remained absent. Neuromuscular monitoring revealed a profound blockade, indicating prolonged suxamethonium-induced paralysis. Arterial blood gas results were normal.</p>

<p>The patient remained in the operating room for nearly two and a half hours before spontaneous breathing resumed. The LMA was removed once an appropriate tidal volume was achieved through spontaneous breathing. On room air, his SpO2 levels remained between 97% and 99%. However, motor weakness persisted, with the child unable to lift his lower limbs and only making slight upper limb movements. Therefore, to rule out a stroke, a pediatric neurology consultation was arranged in the recovery room, and a CT scan was recommended. The CT scan results were normal.</p>

<p><strong>Diagnosis and Treatment</strong></p>

<p>Given the delayed recovery, pseudocholinesterase deficiency leading to suxamethonium apnea was suspected. The child was transferred to the recovery room for close monitoring. The child was then treated with 250 ml of fresh frozen plasma (FFP), which led to a rapid improvement in muscle strength and resolution of weakness.</p>

<p><strong>Outcome</strong></p>

<p>The patient was discharged to the ward and subsequently discharged from the hospital the next day without further complications.</p>

<p><strong>CONCLUSION</strong></p>

<p>This case highlights the rare but significant complication of prolonged apnea following the administration of suxamethonium, likely due to pseudocholinesterase deficiency or an atypical response to the drug. Although suxamethonium is commonly used for rapid muscle relaxation in pediatric anesthesia, its potential for causing extended paralysis underscores the importance of neuromuscular monitoring and vigilant postoperative care. In cases like this, an alternative muscle relaxant such as rocuronium may be a better option for managing bronchospasm, as it avoids the risk of prolonged paralysis and is easily available. Early recognition of suxamethonium-induced apnea and appropriate management, including mechanical ventilation, the use of commercial cholinesterase, and administration of fresh frozen plasma (FFP), is crucial. This case emphasizes the need for thorough preoperative assessment and careful selection of muscle relaxants for future procedures.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Zhou W, Lv S. (2016). Delayed recovery from paralysis associated with plasma cholinesterase deficiency. Springerplus. 5(1):1887.</li>
	<li>Brazzolotto X, Courcelle S, Sauvanet C, Guillon V, Igert A, Kononchik J, et al. (2021). Characterization of four BCHE mutations associated with prolonged effect of suxamethonium. Pharmacogenomics J. 21(2):165-173.</li>
	<li>Zhu GD, Dawson E, Huskey A, Gordon RJ, Del Tredici AL. (2020). Genetic Testing for&nbsp;<em>BCHE</em>&nbsp;Variants Identifies Patients at Risk of Prolonged Neuromuscular Blockade in Response to Succinylcholine. Pharmgenomics Pers Med. 13:405-414.</li>
	<li>Maiorana A, Roach RB Jr. (2003). Heterozygous pseudocholinesterase deficiency: a case report and review of the literature. J Oral Maxillofac Surg. 61(7):845-847.</li>
	<li>Pradhan BK, van Helmond N, Mitrev LV, Andonakakis AA. (2021). Hereditary pseudocholinesterase deficiency discovery after electroconvulsive therapy. BMJ Case Rep. 14(1):e239206.</li>
	<li>Mary W. (1967). The Pseudocholinesterase Variants. A Study of Fourteen Families Selected via the Fluoride Resistant Phenotype. Acta Genetica et Statistica Medica. 17(1):1-12.</li>
	<li>Elamin B. (2003). Dibucaine inhibition of serum cholinesterase. J Biochem Mol Biol. 36(2):149-153.</li>
	<li>Benner A, Lewallen NF, Sadiq NM. Biochemistry, Pseudocholinesterase. [Updated 2022 Sep 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available at: <a href="https://www.ncbi.nlm.nih.gov/books/NBK545284/">https://www.ncbi.nlm.nih.gov/books/NBK545284/</a></li>
	<li>Pol M, Joshi L. (2021). Prolonged Apnoea after Suxamethonium, Diagnosis &amp; Treatment: A Case Report. VIMS Health Science Journal. 8(4):149-150.</li>
	<li>Stovner J, Stadskleiv K. (1976). Suxamethonium apnoea terminated with commercial serumcholinesterase. Acta Anaesthesiol Scand. 20(3):211-215.</li>
</ol>

                    [sm_link] => 
                    [published_dt] => 07-11-2024
                    [vol_name] => Volume 5
                    [vol_year] => 2024
                    [issue] => 1
                    [issue_status] => 2
                    [j_name] => Mathews Journal of Anesthesia
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_page_url] => anesthesia
                )

            [1] => stdClass Object
                (
                    [fixed_date] => 2024-09-14
                    [id] => 1046
                    [title] => Comparison Between General and Spinal Anesthesia in The Effect On Hemodynamic Stability in Patients Undergoing Hernia Repair
                    [type] => Research Article
                    [page_url] => comparison-between-general-and-spinal-anesthesia-in-the-effect-on-hemodynamic-stability-in-patients-undergoing-hernia-repair
                    [vol_id] => 191
                    [issue_id] => 306
                    [image] => comparison-between-general-and-spinal-anesthesia-in-the-effect-on-hemodynamic-stability-in-patients-undergoing-hernia-repair.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Adnan Abdul Adheem Kadhim<sup>1</sup>, Haider Ahmed Jalab Salem Al-Khikani<sup>2,</sup>*, Qasim Muhammad Hamza<sup>3</sup>, Yass Khudair Habib<sup>4</sup>, Muhammad Mohsen Hussein<sup>5</sup>, Hassan Taqi Muhammad<sup>6</sup></strong></p>

                    [about] => <p>Kadhim AAA, et al. (2024). Comparison Between General and Spinal Anesthesia in The Effect On Hemodynamic Stability in Patients Undergoing Hernia Repair. Mathews J Anesth. 5(1):15.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p><sup>1</sup>General Surgery Specialty, Academic Professor of the Department of Anesthesia and&nbsp;Intensive Care Technologies, Al-Taff University College, Karbala, Iraq</p>

<p><sup>2-5</sup>Bachelor of Anesthesia and&nbsp;Intensive Care Technology, Al-Taff University College, Karbala, Iraq</p>

<p><strong>*Corresponding author:</strong> Haider Ahmed Jalab Salem Al-Khikani, Bachelor of Anesthesia and Intensive Care Technology, Al-Taff University College, Karbala, Iraq, Tel: 07729761444, ORCID: 0009-0008-5416-1498; Email: <a href="mailto:hider.ahmed.j@gmail.com">hider.ahmed.j@gmail.com</a></p>

<p><strong>Received Date:</strong> July 23, 2024</p>

<p><strong>Published Date:</strong> September 14, 2024</p>

<p><strong>Citation:</strong> Kadhim AAA, et al. (2024). Comparison Between General and Spinal Anesthesia in The Effect On Hemodynamic Stability in Patients Undergoing Hernia Repair. Mathews J Anesth. 5(1):15.</p>

<p><strong>Copyrights:</strong> Kadhim AAA, et al. &copy; (2024).</p>

<p><strong>ABSTRACT</strong></p>

<p><strong>Introduction</strong><strong>:</strong> The primary focus of the staff in the anesthesia and critical care unit remains selecting the best anesthesia that poses the least risk to the patient&#39;s life. This includes adhering to protocols, protocols, strategies, and guidelines for selecting the most appropriate anesthesia. It might also be argued that the most effective and common type of anesthetic used for hernia repairs is spinal anesthesia. <strong>Aim of the study: </strong>Learn about obtaining and verifying hemodynamic stability in patients undergoing hernia repair under anesthesia. <strong>Subjects and methods</strong>: precise and current analyses of the patients who visit the Karbala hospitals Al-Hassan and Al-Hussein. We classified the 100 patients who had herniotomies into two groups based on the kinds of anesthesia spinal and general. A total of 50 patients underwent spinal anesthesia and 50 patients underwent general anesthesia. Analysis was done on the patient&#39;s blood pressure change, and pulse rate. The study examined patients between the ages of 20 and 90, splitting them into two groups for meticulous follow-up prior to, during, and following surgeries general anesthesia (GA) and spinal anesthesia (SA). <strong>Results</strong><strong>:</strong> Our findings demonstrate that while blood pressure is more constant in SA (about 56%) compared to GA (approximately 40%), blood pressure is higher in GA (32%) and SA (24%) but lower in GA (28%) and SA (20%). Based on the results of this study, heart rate stability is higher in SA (56%) compared to GA (32%), and heart rate increase was 34% in SA and 60% in GA. While the impact of SA is more sustained, the lowered heart rate was 10% in SA and roughly 8% in GA. <strong>Conclusions:</strong> we found spinal anesthesia was more than general anesthesia in stability of blood pressure and heart rate and Minimum or normal.</p>

<p><strong>Keywords:</strong>&nbsp;General Anesthesia, Spinal Anesthesia, Hemodynamic Stability in Anesthesia, Hemodynamic Stability Hernia Repair in Anesthesia.</p>

                    [full_text] => <p><sup>1</sup>General Surgery Specialty, Academic Professor of the Department of Anesthesia and&nbsp;Intensive Care Technologies, Al-Taff University College, Karbala, Iraq</p>

<p><sup>2-5</sup>Bachelor of Anesthesia and&nbsp;Intensive Care Technology, Al-Taff University College, Karbala, Iraq</p>

<p><strong>*Corresponding author:</strong> Haider Ahmed Jalab Salem Al-Khikani, Bachelor of Anesthesia and Intensive Care Technology, Al-Taff University College, Karbala, Iraq, Tel: 07729761444, ORCID: 0009-0008-5416-1498; Email: <a href="mailto:hider.ahmed.j@gmail.com">hider.ahmed.j@gmail.com</a></p>

<p><strong>Received Date:</strong> July 23, 2024</p>

<p><strong>Published Date:</strong> September 14, 2024</p>

<p><strong>Citation:</strong> Kadhim AAA, et al. (2024). Comparison Between General and Spinal Anesthesia in The Effect On Hemodynamic Stability in Patients Undergoing Hernia Repair. Mathews J Anesth. 5(1):15.</p>

<p><strong>Copyrights:</strong> Kadhim AAA, et al. &copy; (2024).</p>

<p><strong>ABSTRACT</strong></p>

<p><strong>Introduction</strong><strong>:</strong> The primary focus of the staff in the anesthesia and critical care unit remains selecting the best anesthesia that poses the least risk to the patient&#39;s life. This includes adhering to protocols, protocols, strategies, and guidelines for selecting the most appropriate anesthesia. It might also be argued that the most effective and common type of anesthetic used for hernia repairs is spinal anesthesia. <strong>Aim of the study: </strong>Learn about obtaining and verifying hemodynamic stability in patients undergoing hernia repair under anesthesia. <strong>Subjects and methods</strong>: precise and current analyses of the patients who visit the Karbala hospitals Al-Hassan and Al-Hussein. We classified the 100 patients who had herniotomies into two groups based on the kinds of anesthesia spinal and general. A total of 50 patients underwent spinal anesthesia and 50 patients underwent general anesthesia. Analysis was done on the patient&#39;s blood pressure change, and pulse rate. The study examined patients between the ages of 20 and 90, splitting them into two groups for meticulous follow-up prior to, during, and following surgeries general anesthesia (GA) and spinal anesthesia (SA). <strong>Results</strong><strong>:</strong> Our findings demonstrate that while blood pressure is more constant in SA (about 56%) compared to GA (approximately 40%), blood pressure is higher in GA (32%) and SA (24%) but lower in GA (28%) and SA (20%). Based on the results of this study, heart rate stability is higher in SA (56%) compared to GA (32%), and heart rate increase was 34% in SA and 60% in GA. While the impact of SA is more sustained, the lowered heart rate was 10% in SA and roughly 8% in GA. <strong>Conclusions:</strong> we found spinal anesthesia was more than general anesthesia in stability of blood pressure and heart rate and Minimum or normal.</p>

<p><strong>Keywords:</strong>&nbsp;General Anesthesia, Spinal Anesthesia, Hemodynamic Stability in Anesthesia, Hemodynamic Stability Hernia Repair in Anesthesia.</p>

<p dir="LTR"><strong>INTRODUCTION</strong></p>

<p dir="LTR">Hernia treatment plans come with a number of difficulties, including postoperative analgesic medication and anesthesia for the process. Spinal and general anesthesia techniques are used during open inguinal hernia surgery [1]. Children with hypertension are known to have end-organ damage and are at risk of developing hypertension as adults, despite the lack of research regarding the long-term effects of persistent hypertension in children [2]. Hypertension is a major risk factor for stroke, coronary artery disease, and kidney damage in adults. Monitoring for the American Society of Anesthesiologists standard involves keeping an eye on the patient&#39;s temperature, circulation, breathing, and oxygenation. It is necessary to use a second pulse oximeter to measure pre- and post-ductal oxygen saturation in addition to routine monitoring. The onset of a gradient between the pre- and post-ductal oxygen saturations may signal pulmonary hypertension exacerbation [3]. Propofol lowers systemic vascular resistance, myocardial contractility, and preload to lower arterial blood pressure. Extremes in age, heart dysfunction, and higher dosages all increase the severity of these consequences. Injection pain and infrequent thrombophlebitis About 58% of injectable users of propofol report experiencing pain [4]. While most patients&#39; blood pressure should return to normal several months prior to surgery, modest to severe diastolic or systolic hypertension does not raise the risk of anesthesia. Acute management of mild to moderate elevations shouldn&#39;t be done in the days leading up to surgery. Increased operating risk is associated with higher blood pressure increases, which need to be carefully managed prior to surgery [5]. Since Bassini&#39;s first description of inguinal hernia repair was published in 1887, other hernia repair techniques have been published, including Shouldice, Darning, Modified Bassini, Lichtenstein mesh repair, and the more recent laparoscopic treatment. Recent times have seen an increase in the popularity of laparoscopic and Lichtenstein mesh repairs due to their rapid recovery periods and low rates of recurrence [6]. Pulmonary aspiration of stomach contents and failed endotracheal intubation are the two leading causes of maternal morbidity and death following general anesthesia. Intravenous ranitidine 50 mg or metoclopramide 10 mg, or both, should be administered to patients who have extra risk factors that make them more prone to aspiration, one to two hours before general anesthesia is induced. Morbid obesity, reflux symptoms, a potentially problematic airway, and emergency surgery performed without a voluntary fasting interval are some of these risk factors. Antacid prophylaxis against aspiration pneumonia should be administered to all patients 30 to 45 minutes before induction using 30 mL of sodium citrate. 40 mg of omeprazole taken orally as a premedication [7]. Propofol primary cardiovascular action is a reduction in arterial blood pressure brought on by a decrease in cardiac contractility, preload, and systemic vascular resistance (the inhibition of sympathetic vasoconstrictor activity). Following induction, hypotension is typically reversed by the stimulation that comes with intubation and laryngoscopy. Propofol-induced hypotension is linked to several factors, such as large dosages, fast injections, and advanced age. The typical arterial baroreflexes response to hypotension is significantly impaired by propofol [8]. When comparing sevoflurane and isoflurane mixed with 67% nitrous oxide for single vital-capacity breath inhalational induction in 67 adults, it was shown to be unsuitable [9]. The hemodynamic reactions to halothane induction and maintenance of anesthesia in 68 unplanned children aged 1-3 undergoing adenoidectomy were compared with those of sevoflurane [10]. The three anesthetic choices for open groin hernia therapy are not available for all procedures. Many conditions must be met for the perfect anesthetic method. It must be simple, as safe as possible, and have minimal postoperative morbidity. The technique must be painless for the patient, provide a swift recovery without any negative consequences after surgery, and be reasonably priced [11].</p>

<p dir="LTR">Aim of the study The failure to achieve circulatory stability for patients suffering from hernia repair under general and spinal anesthesia is what prompted us to provide clear solutions to avoid this problem and prevent all complications that reduce morbidity and mortality.</p>

<p dir="LTR"><strong>SUBJECTS AND METHODS</strong></p>

<p dir="LTR">In this study, we take 100 patients make herniectomy operation which divided into two groups of 50 subjects each (50 general anesthesia and 50 spinal anesthesia), A data analysis was done regarding the change in blood pressers and heart rate, in this study the patients were selected from twenty years to ninety years old, then divided into two groups, the patients were divided two groups: the general anesthesia group GA and the second group spinal anesthesia group SA. we listed the things that can be monitored well in the operating room and divided them into three periods before and during and after the operation, as the information that we collected was blood pressure and the variables that accompany it, such as high or low pressure, the heart rate as well, and the accompanying highs and lows, and MAP, which is that the patient went into one of the shocks from lack of fluids or cardiac shocks, Inhaled anesthetics the It is a type of anesthesia that one should be careful of because it causes a hypotension when used, Minimum alveolar concentration (MAC) inhaled anesthetic amount that in (50%) of individuals stops movement in response to a standardized stimulus (such as surgical area). Because it replicates brain partial pressure, enables potency comparisons among drugs, and offers a benchmark for experimental assessments. Spinal anesthesia provides an alternative to general anesthesia. Although a spinal anesthetic prevents pain during surgery by numbing the lower body, those who have received one might remain conscious during the procedure. Most surgeries performed below the waist can be performed under a spinal anesthetic. An anesthetist administers a spinal anesthetic Using Bupivacaine, which is the preferred and most commonly used drug in operations. Using propofol which is the preferred and most commonly used drug for general anesthesia has the greatest effect on systemic blood pressure when compared to other induction medicines; this is due to substantial vasodilation in both arterial and venous circulations, which leads to decreases in preload and afterload. This effect on systemic blood pressure is particularly significant with age, in individuals with low intravascular fluid capacity, and after a fast injection. Because the hypotensive effects are amplified by the suppression of the usual baroreflexes response, vasodilation causes only a little rise in heart rate.</p>

<p dir="LTR"><strong>RESULTS</strong></p>

<p dir="LTR">In this study, as indicated by the Table in Distribution of Patients to the Change in Blood Pressure, we find that blood pressure is also more stable in SA (about 56%) compared to GA (about 40%); however, blood pressure increases in GA (about 32%) and in SA (about 24%), while blood pressure decreases in GA (about 28%) and in SA (20%). Based on the data presented above, it can be concluded that spinal anesthesia has a more consistent blood pressure profile than general anesthesia.</p>

<p dir="LTR" style="text-align: center;"><strong>Table 1.</strong> Distribution of patients according to the change in Blood Pressure</p>

<table align="center" border="0" cellpadding="0" cellspacing="0" dir="ltr">
	<tbody>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>NO. OF PATIENT</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>INCREASE IN HR</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>REMAIN</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>DECREASE IN HR</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>TOTAL</strong></p>
			</td>
		</tr>
		<tr>
			<td rowspan="2" style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>GA GROUP</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">30</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">16</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">4</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">50</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">60%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">32%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">8%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
		<tr>
			<td rowspan="2" style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>SA GROUP</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">17</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">28</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">5</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">50</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">34%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">56%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">10%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
		<tr>
			<td rowspan="2" style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>TOTAL</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">47</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">44</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">9</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">47%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">44%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">9%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear:both;">According to Table (2), which displays the distribution of patients according to heart rate changes, there is greater stability in the heart rate in SA (56%) compared to GA (32%), and in GA (60%) compared to SA (34%). The percentage of patients experiencing a decrease in heart rate was 10% in SA and approximately 8% in GA. The effect of SA is also more stable.</div>

<p dir="LTR" style="text-align: center;"><strong>Table 2. </strong>Distribution of patients according to the change in Heart rate</p>

<table align="center" border="0" cellpadding="0" cellspacing="0" dir="ltr">
	<tbody>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>NO. OF PATIENT</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>INCREASE IN BLOOD PRESSURE</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>REMAIN</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>DECREASE IN BLOOD PRESSURE</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>TOTAL</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>GA GROUP</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">16</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">20</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">14</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">50</p>
			</td>
		</tr>
		<tr>
			<td style="height: 20px; text-align: center;">&nbsp;</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">32%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">40%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">28%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>SA GROUP</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">12</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">28</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">10</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">50</p>
			</td>
		</tr>
		<tr>
			<td style="height: 20px; text-align: center;">&nbsp;</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">24%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">56%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">20%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;"><strong>TOTAL</strong></p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">28</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">48</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">24</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100</p>
			</td>
		</tr>
		<tr>
			<td style="height: 20px; text-align: center;">&nbsp;</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">28%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">48%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">24%</p>
			</td>
			<td style="height:20px">
			<p dir="LTR" style="text-align: center;">100%</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/Figure%201.png" style="height:303px; width:600px" /></div>

<p dir="LTR" style="text-align: center;"><strong>Figure 1.</strong> The Relationship between age GA and Mean Arterial Pressure GA.</p>

<p dir="LTR">that the is likewise more stable in SA (about 56%) compared to GA (approximately 40%). Without therapy, however, blood pressure increases are higher in GA (32%) and SA (24%), while blood pressure decreases are also higher in GA (28%) and SA (20%).</p>

<p dir="LTR" style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/Figure%202.png" style="height:313px; width:600px" /></p>

<p dir="LTR" style="text-align: center;"><strong>Figure 2.</strong> The Relationship Mean Arterial Pressure GA</p>

<p dir="LTR">Additionally, blood pressure in SA is more stable at roughly (56%) compared to about (40%) in GA; yet, blood pressure in GA is more likely to raise at (32%) and decrease at (28%). Thus, based on the data and statistics that are currently in front of you, it can be concluded that spinal anesthesia is superior and more stable.</p>

<p dir="LTR"><strong>DISCUSSION</strong></p>

<p dir="LTR">Courtney J. Balentine, inguinal hernia repair is the most common general surgery procedure in the United States (15%&ndash;20%) of these procedures are performed under general anesthesia, whereby local anesthetic is used for the remaining 80% of the procedure. We postulated that as people age, there would be more benefits to local anesthetic for inguinal hernia surgery as opposed to general anesthesia [12]. Bay-Nielsen, regional anesthesia has the highest morbidity and local infiltration anesthesia has the lowest morbidity. The elective groin hernia repair procedure had a (0.12%) mortality rate within (30 days), with patients dying within a week more likely to have received regional anesthesia [13]. Anthony Rodgers, Neuraxial blocking lowers major problems such as postoperative mortality. The magnitude of some of these benefits and whether they are solely related to avoiding general anesthesia, all-cause mortality, DVT, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure require more research [14]. David L Reich, found that severe hypotension after induction of anesthesia is quite typical, as compared to other times, it occurs more frequently in the (5&ndash;10 minute late post-induction interval). In conclusion, it is wise to think about alternatives to propofol when inducing anesthesia in patients older than (50 with an ASA physical status of III). In standard clinical practice, (9%) of patients experienced clinically significant hypotension in the first ten minutes following anesthetic induction [15]. Al-Khikani et al Owners of this research study a comparison between general and spinal anesthesia in the effect on hemodynamic stability in patients Undergoing hernia repair, having a hernia repaired, the cardiovascular system is unaffected by spinal anesthesia, which has been shown via study to be more stable than general anesthesia. Nevertheless, the benefit must be increased by precise and accurate work rather than reliance. Monitoring and correcting blood circulation abnormalities is essential.</p>

<p dir="LTR"><strong>CONCLUSIONS</strong></p>

<p dir="LTR">We found a very noticeable increase in heart rate in general anesthesia, while spinal anesthesia was more stable, mean arterial pressure (MAP) We found a very noticeable increase in arterial pressure in general anesthesia, while spinal anesthesia was more stable, Blood pressure (PB) We found a very noticeable increase in pressure in general anesthesia, while spinal anesthesia was more stable. Achieving hemodynamic stability is crucial for balancing the supply and demand of oxygen in the heart, to achieve an identical objective, many agents and methods may be employed, includes fentanyl plus isoflurane, sevoflurane, or propofol, through a variety of mechanisms, volatile anesthetics exert cardio-protective effects [16]. The science and training are in line with the American Heart Association Guidelines Update for CPR and Emergency Cardiovascular Care, The American Heart Association&#39;s BLS course is recommended for healthcare professionals and other staff members who need to learn how to perform CPR and other basic cardiovascular life support procedures in a variety of scenarios [17]. A significant portion of individuals receiving general anesthesia are susceptible to the common occurrence of intraoperative hypotension (IH) Significant postoperative sequelae, including as renal failure, cardiac damage, and even higher mortality, are associated with the incidence of IH [18].</p>

<p dir="LTR"><strong>REFERENCES</strong></p>

<ol dir="ltr">
	<li>Callesen T. (2003). Inguinal hernia repair: anaesthesia, pain and convalescence. Dan Med Bull. 50(3):203-218.</li>
	<li>Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh R. (2014). Pharmacological interventions for hypertension in children. Cochrane Database Syst Rev. 2:CD008117.</li>
	<li>Aglio LS, Urman RD. (2017). Anesthesiology: Clinical Case Reviews. 10.1007/978-3-319-50141-3<span dir="RTL">.</span></li>
	<li>Forkin KT, Nemergut EC. (2016). Miller&rsquo;s anesthesia, 8<sup>th</sup> edition [Internet]. American Society of Anesthesiologists. [cited 2024 Jan 1].</li>
	<li>Wolfsthal SD. (1993). Is blood pressure control necessary before surgery? Med Clin North Am. 77(2):349-363<span dir="RTL">.</span></li>
	<li>Mabula JB, Chalya PL. (2012). Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting. BMC Res Notes. 5:585.</li>
	<li>Aitkenhead AR, Moppett I, Thompson J. (2013). Smith and Aitkenhead&rsquo;s Textbook of Anaesthesia. Elsevier Health Sciences<span dir="RTL">.</span></li>
	<li>Butterworth JF. (2018). Morgan and mikhail&rsquo;s clinical anesthesiology. 6<sup>th</sup> ed. McGraw-Hill Education<span dir="RTL">.</span></li>
	<li>Ti LK, Pua HL, Lee TL. (1998). Single vital capacity inhalational anaesthetic induction in adults--isoflurane vs sevoflurane. Can J Anaesth. 45(10):949-953.</li>
	<li>Meyler L, Aronson JK. (2009). Meyler&rsquo;s side effects of drugs used in anesthesia. Amsterdam: Elsevier Science<span dir="RTL">.</span></li>
	<li>Kingsnorth A, Leblanc KA, Sanders DL. (2018). Management of Abdominal Hernias. Cham: International Publishing.</li>
	<li>Balentine CJ, Meier J, Berger M, Reisch J, Cullum M, Lee SC, et al. (2021). Using Local Anesthesia for Inguinal Hernia Repair Reduces Complications in Older Patients. J Surg Res. 258:64-72.</li>
	<li>Bay-Nielsen M, Kehlet H. (2008). Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Acta Anaesthesiol Scand. 52(2):169-174.</li>
	<li>Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. (2000). Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 321(7275):1493.</li>
	<li>Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, et al. (2005). Predictors of hypotension after induction of general anesthesia. Anesth Analg. 101(3):622-628.</li>
	<li>Kaplan JA, Augustine&#39;s JGT, Manecke GR, et al, eds. (2017). Kaplan&#39;s Cardiac Anesthesia for Cardiac and Noncardiac Surgery. 7<sup>th</sup> edn. Philadelphia, PA: Elsevier. pp. 731.L -769.L.</li>
	<li>Pardo M. (2022). Miller&rsquo;s Basics of Anesthesia. Elsevier Health Sciences.</li>
	<li>Benes J, Simanova A, Tovarnicka T, Sevcikova S, Kletecka J, Zatloukal J, et al. (2015). Continuous non-invasive monitoring improves blood pressure stability in upright position: randomized controlled trial. J Clin Monit Comput. 29(1):11-17.</li>
</ol>

                    [sm_link] => 
                    [published_dt] => 14-09-2024
                    [vol_name] => Volume 5
                    [vol_year] => 2024
                    [issue] => 1
                    [issue_status] => 2
                    [j_name] => Mathews Journal of Anesthesia
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_page_url] => anesthesia
                )

            [2] => stdClass Object
                (
                    [fixed_date] => 2023-07-27
                    [id] => 802
                    [title] => Sugammadex: A Miracle Drug, but is Further Research Needed?
                    [type] => Letter to the Editor
                    [page_url] => sugammadex-a-miracle-drug-but-is-further-research-needed
                    [vol_id] => 174
                    [issue_id] => 262
                    [image] => sugammadex-a-miracle-drug-but-is-further-research-needed.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Girishkumar Modi*, Vijay Kumar</strong></p>

                    [about] => <p>Modi G, et al. (2023). Sugammadex: A Miracle Drug, but is Further Research Needed? Mathews J Anesth. 4(2):14.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p>Specialist Anesthesiologist, Tawam Hospital, UAE</p>

<p><strong>*Corresponding author:</strong> Girishkumar Modi, Specialist Anesthesiologist, Tawam Hospital, UAE, Email: <a href="mailto:girishmodi75@gmail.com">girishmodi75@gmail.com</a>.</p>

<p><strong>Received Date:</strong> July 13, 2023</p>

<p><strong>Published Date:</strong> July 27, 2023</p>

<p><strong>Citation:</strong> Modi G, et al. (2023). Sugammadex: A Miracle Drug, but is Further Research Needed? Mathews J Anesth. 4(2):14.</p>

<p><strong>Copyrights:</strong> Modi G, et al. &copy; (2023).</p>

<p><strong>LETTER TO EDITOR</strong></p>

<p>Sugammadex is a drug that changes the practice of general anesthesia and is considered a revolutionary drug in neuromuscular physiology [1]. It is modified gamma-cyclodextrin, used as a reversal agent for steroidal non-depolarized muscle relaxants (NDMR). It encapsulates free NDMR drugs like rocuronium and vecuronium at NMJ. The core part of the drug is enough large to encapsulate the NDMR drugs. It is a worldwide available and FDA approved drug.</p>

<p>Sugammadex is commonly used as an NDMR reversal agent (mainly rocuronium) in bariatric surgery for obesity with a BMI greater than 30, patients with compromised respiratory reserve (asthma and COPD), and the geriatric age group. Using sagammadex, the muscarinic S/E of neostigmine (nausea, vomiting, bradycardia, diarrhea, etc.) and the anti-muscarinic S/E (dry mouth, palpitation, urinary retention, constipation, etc.) of glycopyrrolate can be avoided. Sugammadex is approved to be used as an NDMR reversal agent for 2-year-old and older age groups, and studies have demonstrated that it has similar efficacy and S/E in this age group as compared to adults. The cost of sugammadex is a significant consideration that may restrict its use as a regular antagonist of neuromuscular-blocking medications.</p>

<p>There are a few studies that demonstrate sugammadex has a favorable post-operative respiratory outcome. Recently, in 2023, a systemic review and meta-analysis were conducted by Hong-Mei Liu et al. to determine whether reversal with sugammadex was linked to a lower risk of post-operative complications as compared to neostigmine. The study concluded that the incidence of post-operative pulmonary complications (PPC: airway obstruction, requirement of NIV, pleural effusion, pneumonia, and atelectasis) is lower with sugammadex when compared to neostigmine [2]. Another RCT was conducted in 2023 by Huang et al. on sugammadex vs. neostigmine for the evaluation of respiratory muscle strength recovery by using ultrasound in the post-extubation period [3]. They concluded that immediately after extubation, expiratory muscle strength recovery is enhanced with sugammadex than neostigmine. However, they also noticed that the strength of the respiratory muscles in most of the patients did not recover completely for half an hour after their arrival in the post-operative recovery room after extubation. Eventually this might lead to post-operative pulmonary complications, as discussed above. Yet another meta-analysis comparing neostigmine versus sugammadex for neuromuscular blockade reversal showed that residual paralysis is decreased with sugammadex as compared to neostigmine [4]. In addition, cases of post-operative recurarization and residual paralysis in surgical patients after sugammadex were also reported [5,6].</p>

<p>Studies suggest that residual (re-curarization) neuromuscular blockade or insufficient respiratory muscle strength are still present with sugammadex as a reversal agent, but to a much lesser extent compared to neostigmine. Residual neuromuscular blockade or re-curarization if TOF ratio is less than 0.9 is one of the known causes of respiratory muscle dysfunction that can lead to complications after surgery. This might lead to atelectasis, aspiration, pneumonia, and reintubation [7]. Ultimately, it may lead to a prolonged hospital stay, nosocomial infection, and financial burden.</p>

<p>In current clinical practice, the recommended dose for sugammadex is 2 to 4 milligrams per kg, which can go up to 16 mg/kg depending on the last dosage of NDMR agents. The exact dose of sugammadex required in altered physiology (ex., pregnancy, patients with critical illness, malnourished patients, elderly patients with renal and liver disease, inborn errors of metabolism, etc.) is still not clear. Recurrence or residual neuromuscular blockade after sugammadex is caused by the redistribution of unbound rocuronium molecules toward the NMJ or an insufficient dose of sugammadex to encapsulate rocuronium molecules. After sugammadex administration, unbound rocuronium molecules move rapidly from the NMJ site to the plasma site due to the concentration gradient difference between these two sites [8]. If the sugammadex dose is inadequate or less than what is needed to encapsulate rocuronium molecules, unbound or free rocuronium molecules move or redistribute towards the NMJ site along with the concentration gradient and produce paralysis. As residual neuromuscular blockade is associated with post-operative pulmonary complications, anesthesiologists should consider using NM monitoring peri-operatively in order to decrease the PPC associated with residual neurological blockade.</p>

<p>Lastly, re-establishment of the NMB after sugammadex is also a bit challenging as free molecules of sugammadex present at the NMJ encapsulate the rocuronium. Therefore, rocuronium&#39;s onset of action may be delayed, and its duration may be reduced [9]. Therefore, a higher dose of rocuronium is required to produce NMB, or we need to search for an alternate group of NDMR drugs.</p>

<p>In summary, post-operative pulmonary complications associated with residual neuromuscular blockade are less common with sugammadex as compared to neostigmine. Sugammadex is rarely associated with serious side effects in clinical practice. Although, raised a few interesting issues, and it&#39;s convincing that it&#39;s worth further research.&nbsp;A few cases of anaphylaxis have been reported following the administration of sugammadex [10]. Moreover, case reports of bradycardia and asystole [11] and cardiac arrest [12] (due to coronary vasospasm) after sugammadex were also reported. &nbsp;It is acknowledged that sugammadex is a &quot;magic drug&quot; that has changed anaesthesia practice; however, further prospective, large-scale, multi-center trials research are needed to demonstrate that it has a positive impact on anaesthesia practice, particularly in the context of neuromuscular physiology.</p>

<p><strong>ABBREVIATIONS</strong></p>

<p>NDMR: Non-Depolarizing Muscle Relaxant; NMJ: Neuromuscular Junction; NMB: Neuromuscular Blockade; BMI: Body Mass Index; COPD: Chronic Obstructive Pulmonary Disease; NIV: Non-Invasive Ventilation; TOF: Train Of Four; S/E: Side Effects; PPC: Post-operative Pulmonary Complications.</p>

<p><strong>CONFLICT OF INTEREST</strong></p>

<p>None.</p>

<p><strong>FUNDING</strong></p>

<p>None.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Nag K, Singh DR, Shetti AN, Kumar H, Sivashanmugam T, Parthasarathy S. (2013). Sugammadex: A revolutionary drug in neuromuscular pharmacology. Anesth Essays Res. 7(3):302-306.</li>
	<li>Liu HM, Yu H, Zuo YD, Liang P. (2023). Postoperative pulmonary complications after sugammadex reversal of neuromuscular blockade: a systematic review and meta-analysis with trial sequential analysis. BMC Anaesthesiology. 23(1):130.</li>
	<li>Huang C, Wang X, Gao S, Luo W, Zhao X, Zhou Q, et al. (2023). Sugammadex Versus Neostigmine for Recovery of Respiratory Muscle Strength Measured by Ultrasonography in the Postextubation Period: A Randomized Controlled Trial. Anesth Analg. 136(3):559-568.</li>
	<li>Abad-Gurumeta A, Ripoll&eacute;s-Melchor J, Casans-Franc&eacute;s R, Espinosa A, Mart&iacute;nez-Hurtado E, Fern&aacute;ndez-P&eacute;rez C, et al. (2015). A systematic review of sugammadex vs. neostigmine for the reversal of neuromuscular blockade. Anaesthesia. 70(12): 1441-1452.</li>
	<li>Sasakawa T, Miyasaka K, Sawa T, Iida H. (2020). Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience. APSF. 35(2):33-68.</li>
	<li>Uzawa K, Seki H, Yorozu T. (2021). Residual paralysis caused by 50 mg rocuronium after reversal with sugammadex 4 mg/kg: a case report. BMC anesthesiology. 21(1):154.</li>
	<li>Farhan H, Moreno-Duarte I, McLean D, Eikermann M. (2014). Residual paralysis: does it influence outcome after ambulatory surgery? Curr Anesthesiol Rep. 4(4):290-302.</li>
	<li>Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart PA, van Kuijk JHM, et al. (2009). Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients.&nbsp;Anesthesiology. 110(2):284-294.&nbsp;</li>
	<li>Cammu G, de Kam PJ, De Graeve K, van den Heuvel M, Suy K, et al. (2010). Repeat dosing of rocuronium 1.2 mg kg-1 after reversal of neuromuscular block by sugammadex 4.0 mg kg-1 in anesthetized healthy volunteers: a modeling-based pilot study.&nbsp;Br J Anaesth. 105(4):487-492.</li>
	<li>Lazo Uslar C, Navarro Vives L, Miquel Marco S, Roger Reig A, Basaga&ntilde;a Torrento M. (2022). Sugammadex-Induced Anaphylaxis: 2 Case Reports. J Investig Allergol Clin Immunol. 32(2):152-154.</li>
	<li>Hunter JM, Naguib M. (2018). Sugammadex-induced bradycardia and asystole: how great is the risk? Br J Anaesth. 121(1):8-12.</li>
	<li>Boo KY, Park SH, Park SK, Na C, Kim HJ. (2023). Cardiac arrest due to coronary vasospasm after sugammadex administration-a case report. Korean J Anesthesiol. 76(1):72-76.</li>
</ol>

                    [full_text] => <p>Specialist Anesthesiologist, Tawam Hospital, UAE</p>

<p><strong>*Corresponding author:</strong> Girishkumar Modi, Specialist Anesthesiologist, Tawam Hospital, UAE, Email: <a href="mailto:girishmodi75@gmail.com">girishmodi75@gmail.com</a>.</p>

<p><strong>Received Date:</strong> July 13, 2023</p>

<p><strong>Published Date:</strong> July 27, 2023</p>

<p><strong>Citation:</strong> Modi G, et al. (2023). Sugammadex: A Miracle Drug, but is Further Research Needed? Mathews J Anesth. 4(2):14.</p>

<p><strong>Copyrights:</strong> Modi G, et al. &copy; (2023).</p>

<p><strong>LETTER TO EDITOR</strong></p>

<p>Sugammadex is a drug that changes the practice of general anesthesia and is considered a revolutionary drug in neuromuscular physiology [1]. It is modified gamma-cyclodextrin, used as a reversal agent for steroidal non-depolarized muscle relaxants (NDMR). It encapsulates free NDMR drugs like rocuronium and vecuronium at NMJ. The core part of the drug is enough large to encapsulate the NDMR drugs. It is a worldwide available and FDA approved drug.</p>

<p>Sugammadex is commonly used as an NDMR reversal agent (mainly rocuronium) in bariatric surgery for obesity with a BMI greater than 30, patients with compromised respiratory reserve (asthma and COPD), and the geriatric age group. Using sagammadex, the muscarinic S/E of neostigmine (nausea, vomiting, bradycardia, diarrhea, etc.) and the anti-muscarinic S/E (dry mouth, palpitation, urinary retention, constipation, etc.) of glycopyrrolate can be avoided. Sugammadex is approved to be used as an NDMR reversal agent for 2-year-old and older age groups, and studies have demonstrated that it has similar efficacy and S/E in this age group as compared to adults. The cost of sugammadex is a significant consideration that may restrict its use as a regular antagonist of neuromuscular-blocking medications.</p>

<p>There are a few studies that demonstrate sugammadex has a favorable post-operative respiratory outcome. Recently, in 2023, a systemic review and meta-analysis were conducted by Hong-Mei Liu et al. to determine whether reversal with sugammadex was linked to a lower risk of post-operative complications as compared to neostigmine. The study concluded that the incidence of post-operative pulmonary complications (PPC: airway obstruction, requirement of NIV, pleural effusion, pneumonia, and atelectasis) is lower with sugammadex when compared to neostigmine [2]. Another RCT was conducted in 2023 by Huang et al. on sugammadex vs. neostigmine for the evaluation of respiratory muscle strength recovery by using ultrasound in the post-extubation period [3]. They concluded that immediately after extubation, expiratory muscle strength recovery is enhanced with sugammadex than neostigmine. However, they also noticed that the strength of the respiratory muscles in most of the patients did not recover completely for half an hour after their arrival in the post-operative recovery room after extubation. Eventually this might lead to post-operative pulmonary complications, as discussed above. Yet another meta-analysis comparing neostigmine versus sugammadex for neuromuscular blockade reversal showed that residual paralysis is decreased with sugammadex as compared to neostigmine [4]. In addition, cases of post-operative recurarization and residual paralysis in surgical patients after sugammadex were also reported [5,6].</p>

<p>Studies suggest that residual (re-curarization) neuromuscular blockade or insufficient respiratory muscle strength are still present with sugammadex as a reversal agent, but to a much lesser extent compared to neostigmine. Residual neuromuscular blockade or re-curarization if TOF ratio is less than 0.9 is one of the known causes of respiratory muscle dysfunction that can lead to complications after surgery. This might lead to atelectasis, aspiration, pneumonia, and reintubation [7]. Ultimately, it may lead to a prolonged hospital stay, nosocomial infection, and financial burden.</p>

<p>In current clinical practice, the recommended dose for sugammadex is 2 to 4 milligrams per kg, which can go up to 16 mg/kg depending on the last dosage of NDMR agents. The exact dose of sugammadex required in altered physiology (ex., pregnancy, patients with critical illness, malnourished patients, elderly patients with renal and liver disease, inborn errors of metabolism, etc.) is still not clear. Recurrence or residual neuromuscular blockade after sugammadex is caused by the redistribution of unbound rocuronium molecules toward the NMJ or an insufficient dose of sugammadex to encapsulate rocuronium molecules. After sugammadex administration, unbound rocuronium molecules move rapidly from the NMJ site to the plasma site due to the concentration gradient difference between these two sites [8]. If the sugammadex dose is inadequate or less than what is needed to encapsulate rocuronium molecules, unbound or free rocuronium molecules move or redistribute towards the NMJ site along with the concentration gradient and produce paralysis. As residual neuromuscular blockade is associated with post-operative pulmonary complications, anesthesiologists should consider using NM monitoring peri-operatively in order to decrease the PPC associated with residual neurological blockade.</p>

<p>Lastly, re-establishment of the NMB after sugammadex is also a bit challenging as free molecules of sugammadex present at the NMJ encapsulate the rocuronium. Therefore, rocuronium&#39;s onset of action may be delayed, and its duration may be reduced [9]. Therefore, a higher dose of rocuronium is required to produce NMB, or we need to search for an alternate group of NDMR drugs.</p>

<p>In summary, post-operative pulmonary complications associated with residual neuromuscular blockade are less common with sugammadex as compared to neostigmine. Sugammadex is rarely associated with serious side effects in clinical practice. Although, raised a few interesting issues, and it&#39;s convincing that it&#39;s worth further research.&nbsp;A few cases of anaphylaxis have been reported following the administration of sugammadex [10]. Moreover, case reports of bradycardia and asystole [11] and cardiac arrest [12] (due to coronary vasospasm) after sugammadex were also reported. &nbsp;It is acknowledged that sugammadex is a &quot;magic drug&quot; that has changed anaesthesia practice; however, further prospective, large-scale, multi-center trials research are needed to demonstrate that it has a positive impact on anaesthesia practice, particularly in the context of neuromuscular physiology.</p>

<p><strong>CONFLICT OF INTEREST</strong></p>

<p>None.</p>

<p><strong>FUNDING</strong></p>

<p>None.</p>

<p><strong>ABBREVIATIONS</strong></p>

<p>NDMR: Non-Depolarizing Muscle Relaxant; NMJ: Neuromuscular Junction; NMB: Neuromuscular Blockade; BMI: Body Mass Index; COPD: Chronic Obstructive Pulmonary Disease; NIV: Non-Invasive Ventilation; TOF: Train Of Four; S/E: Side Effects; PPC: Post-operative Pulmonary Complications.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Nag K, Singh DR, Shetti AN, Kumar H, Sivashanmugam T, Parthasarathy S. (2013). Sugammadex: A revolutionary drug in neuromuscular pharmacology. Anesth Essays Res. 7(3):302-306.</li>
	<li>Liu HM, Yu H, Zuo YD, Liang P. (2023). Postoperative pulmonary complications after sugammadex reversal of neuromuscular blockade: a systematic review and meta-analysis with trial sequential analysis. BMC Anaesthesiology. 23(1):130.</li>
	<li>Huang C, Wang X, Gao S, Luo W, Zhao X, Zhou Q, et al. (2023). Sugammadex Versus Neostigmine for Recovery of Respiratory Muscle Strength Measured by Ultrasonography in the Postextubation Period: A Randomized Controlled Trial. Anesth Analg. 136(3):559-568.</li>
	<li>Abad-Gurumeta A, Ripoll&eacute;s-Melchor J, Casans-Franc&eacute;s R, Espinosa A, Mart&iacute;nez-Hurtado E, Fern&aacute;ndez-P&eacute;rez C, et al. (2015). A systematic review of sugammadex vs. neostigmine for the reversal of neuromuscular blockade. Anaesthesia. 70(12): 1441-1452.</li>
	<li>Sasakawa T, Miyasaka K, Sawa T, Iida H. (2020). Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience. APSF. 35(2):33-68.</li>
	<li>Uzawa K, Seki H, Yorozu T. (2021). Residual paralysis caused by 50 mg rocuronium after reversal with sugammadex 4 mg/kg: a case report. BMC anesthesiology. 21(1):154.</li>
	<li>Farhan H, Moreno-Duarte I, McLean D, Eikermann M. (2014). Residual paralysis: does it influence outcome after ambulatory surgery? Curr Anesthesiol Rep. 4(4):290-302.</li>
	<li>Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart PA, van Kuijk JHM, et al. (2009). Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients.&nbsp;Anesthesiology. 110(2):284-294.&nbsp;</li>
	<li>Cammu G, de Kam PJ, De Graeve K, van den Heuvel M, Suy K, et al. (2010). Repeat dosing of rocuronium 1.2 mg kg-1 after reversal of neuromuscular block by sugammadex 4.0 mg kg-1 in anesthetized healthy volunteers: a modeling-based pilot study.&nbsp;Br J Anaesth. 105(4):487-492.</li>
	<li>Lazo Uslar C, Navarro Vives L, Miquel Marco S, Roger Reig A, Basaga&ntilde;a Torrento M. (2022). Sugammadex-Induced Anaphylaxis: 2 Case Reports. J Investig Allergol Clin Immunol. 32(2):152-154.</li>
	<li>Hunter JM, Naguib M. (2018). Sugammadex-induced bradycardia and asystole: how great is the risk? Br J Anaesth. 121(1):8-12.</li>
	<li>Boo KY, Park SH, Park SK, Na C, Kim HJ. (2023). Cardiac arrest due to coronary vasospasm after sugammadex administration-a case report. Korean J Anesthesiol. 76(1):72-76.</li>
</ol>

                    [sm_link] => 
                    [published_dt] => 27-07-2023
                    [vol_name] => Volume 4
                    [vol_year] => 2023
                    [issue] => 2
                    [issue_status] => 3
                    [j_name] => Mathews Journal of Anesthesia
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_page_url] => anesthesia
                )

            [3] => stdClass Object
                (
                    [fixed_date] => 2023-07-26
                    [id] => 801
                    [title] => The Adductor Canal Nerve Block: A Simple and Effective Approach for Knee Pain
                    [type] => Editorial Article
                    [page_url] => the-adductor-canal-nerve-block-a-simple-and-effective-approach-for-knee-pain
                    [vol_id] => 174
                    [issue_id] => 262
                    [image] => the-adductor-canal-nerve-block-a-simple-and-effective-approach-for-knee-pain.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Girishkumar Modi<sup>1,</sup>*, Umesh Rawal<sup>2</sup></strong></p>

                    [about] => <p>Modi G, et al. (2023). The Adductor Canal Nerve Block: A Simple and Effective Approach for Knee Pain. Mathews J Anesth. 4(2):13.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p><sup>1</sup>Specialist Anesthesiologist, Tawam Hospital, UAE</p>

<p><sup>2</sup>Vedhasaya Pain and Spine Center, Ahmedabad, India</p>

<p><strong>*Corresponding author:</strong> Girishkumar Modi, Specialist Anesthesiologist, Tawam Hospital, UAE, Email: <a href="mailto:girishmodi75@gmail.com">girishmodi75@gmail.com</a>.</p>

<p><strong>Received Date:</strong> July 13, 2023</p>

<p><strong>Published Date:</strong> July 26, 2023</p>

<p><strong>Citation:</strong> Modi G, et al. (2023). The Adductor Canal Nerve Block: A Simple and Effective Approach for Knee Pain. Mathews J Anesth. 4(2):13.</p>

<p><strong>Copyrights:</strong> Modi G, et al. &copy; (2023).</p>

<p><strong>INTRODUCTION</strong></p>

<p>The Adductor Canal, also known as the Hunter Canal, is 8 to 14 cm long and located at the distal two-thirds of the medial thigh. It travels from the apex of the femoral triangle to the adductor hiatus, an aperture in the adductor magnus muscle. The vastus medialis forms the lateral border of the canal, the sartorius forms the medial border, and the adductor longus and magnus muscles form the base. It carries an important structure (saphenous nerve, superficial femoral artery and vein, vastus medialis muscle nerve, and obturator nerve branch) [1] (Figure 1 &amp; 2).</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg1.png" style="height:454px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 1.</strong> Adductor canal Anatomy through the sagittal section of the thigh. Downloaded from <a href="https://en.wikipedia.org/wiki/Adductor_canal#/media/File:Adductor_canal.png">https://en.wikipedia.org/wiki/Adductor_canal#/media/File:Adductor_canal.png</a></p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg2.png" style="height:650px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 2. </strong>Structures Contained within The Adductor Canal.</p>

<p>In ACNB, we focused on the saphenous nerve, a sensory leading branch of the femoral nerve that supply the skin of the medial, posteromedial, and anteromedial aspects of the lower leg from the distal thigh to the medial malleolus [2]. The main advantage of a saphenous nerve block over a femoral nerve block is that it causes less muscle weakness while providing comparable pain control. This means that, when compared to a femoral nerve block [3], it retains quadriceps motor strength and promotes early mobilization. It splits off from the femoral nerve in the upper third of the thigh, goes down next to the femoral sheath in the adductor canal, crosses in front of the femoral artery, and comes out of the canal with the saphenous branch of the descending genicular artery.</p>

<p>ACNB is used to provide anesthesia and analgesia for knee, medial lower leg, and ankle surgery [4]. It is an alternative approach to femoral nerve block for pain control after various knee procedures, especially knee arthroplasty and arthroscopy [5]. It is quite easy and simple to perform by injecting LA agent deep into the sartorius muscle in the adductor canal, and it is a reliable nerve block in terms of pain relief.</p>

<p>Absolute contraindications for nerve blocks include patient refusal, an allergy to Local Anesthetic (LA) agents, and an infection or contamination at the point of injection. Relative contraindications include coagulopathy and neuropathy [6]. However, it is important for patients to understand the procedure, its benefits, and its potential risks before consenting to a nerve block. Patients should be aware that while nerve blocks can provide effective pain relief, there is a small risk of complications such as nerve damage or infection [7]. Standard fasting recommendations ought to be adhered to, just like general anesthesia. Additionally, obtaining intravenous access is necessary because of the potential for adverse effects like vasovagal syncope and local anesthetic toxicity [7].</p>

<p>Apply standard monitoring in accordance with AAGBI guideline, and keep emergency drugs and an airway trolley on hand to handle any potential local anesthetic toxicity [8]. The patient will lie supine with the leg slightly abducted and externally rotated. The most suitable place for the provider to stand is on the same side of the nerve block and adjusts the patient&rsquo;s bed height as per the provider&#39;s comfort.</p>

<p>Turn on the ultrasound machine and tweak the controls to suit your needs (e.g., depth, gain, and focus). Skin disinfectant should be used to clean the area around the adductor canal nerve block site (typically the medial aspect of the knee) to prevent infection. After applying sterile ultrasound gel, the high-frequency linear probe is positioned transversely perpendicular to the long axis of the leg, just above the medial aspect of the knee, where the saphenous nerve is anticipated to be (Figure 3 &amp; 4).</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg3.png" style="height:466px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 3.</strong> Ultrasound image of the Adductor canal Nerve block.</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg4.png" style="height:444px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 4. </strong>Local anesthetic agent infiltration around the saphenous nerve under USG.</p>

<p>As you scan, you should see several structures, including adductor magnus, vastus medialis, sartorius, and the adductor canal. The Adductor canal is triangular space between these muscles, situated beneath the sartorius muscle. Therefore, it is also called Sub-Sartorial canal.</p>

<p>The saphenous nerve is located within the adductor canal, and it runs adjacent to the adductor longus muscle and the femoral artery. The saphenous nerve is visible as an oval or circular hypoechoic (darker) structure close to the femoral artery; use color doppler to identify the artery if required. After identifying the saphenous nerve, switch the ultrasound probe to the long-axis view to guide needle insertion. After local infiltration at site of injection, insert an 80 mm or 100 mm pujunk needle in an in-plane approach with the ultrasound going from the lateral to the medial side of the thigh. Advance the needle tip just lateral to the femoral artery and underneath to the sartorius muscle. After correct needle placement next to the saphenous nerve after piercing vaso-adductor membrane, a negative aspiration is performed to prevent arterial injection. Inject the local anesthetic (0.5 % ropivacaine, 15-20 ml) incrementally around the saphenous nerve, ensuring that the LA agent spreads to completely cover the nerve [2,9]. Finally, remove the needle and apply gentle pressure and a sterile dressing to the injection site. The patient should experience sensory loss in the medial leg and foot following the block. This block can be performed both pre- and post-operatively. Following the procedure, it is critical to monitor the patient&#39;s vitals and look for any complications.</p>

<p>Complications of adductor canal nerve blocks include nerve injury, which can cause temporary or permanent sensory or motor deficits in the affected area, infection, bleeding, or hematoma, allergic reactions, local anesthetic toxicity, and block failure [8].</p>

<p>Adductor canal nerve block can be given continuously using a catheter or as a single shot. Some studies have compared the clinical outcomes of continuous adductor canal block (C-ACB) and Single shot adductor canal block (SACB) after TKA. A meta-analysis of 8 randomized controlled trials involving 702 knees found that C-ACB can achieve better postoperative pain relief at 24 and 48 hours both at rest and after mobilization, a lower amount of opioid consumption at 72 hours, a shorter length of hospital stay, and a larger range of motion than SACB [10]. However, there was no discernible finding among the two methods in terms of quadriceps strength, mobility, and incidence of complications.</p>

<p>To summarize, the adductor canal nerve block is a straightforward, quick, and simple procedure. ACNB represent a novel and efficient form of nerve block that targets the saphenous nerve, a sensory branch of the femoral nerve at the mid-thigh level in the adductor canal for post-operative pain management, particularly in knee surgeries (Knee arthroplasty, knee arthroscopy, and ligament repairs) and assists the patient in early mobilization by preserving quadriceps muscle strength.</p>

<p><strong>ABBREVIATION</strong></p>

<p>ACNB: Adductor Canal Nerve Block; LA: Local Anesthetic; USG: Ultrasonography; C-ACB: Continuous Adductor Canal Block; SACB: Single Shot Adductor Canal Block.</p>

<p><strong>CONFLICT OF INTEREST</strong></p>

<p>None.</p>

<p><strong>FUNDING</strong></p>

<p>None.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Steven LO, Barrington M. (2023). Anatomy for the Adductor Canal Block: Does Location Really Matter? Anesth Analg. 136(3):455-457.</li>
	<li>Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R. (2009). Feasibility, and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med. 34(6):578-580.</li>
	<li>El-Ghandour AM, Mohamed AS, Abosief EMK, El‑Fattah Ghoneim MMA, Ahmad AHM, et al. (2022). Saphenous Nerve Block Versus Femoral Nerve Block in Enhanced Recovery After Knee Replacement Surgery Under Spinal Anaesthesia. Ain-Shams Journal of Anesthesiology. 14(1):56.</li>
	<li>Serkan T, Selvi O. (2018). Ultrasound Guided Distal Adductor Canal Block Provides Effective Postoperative Analgesia in Lower Leg Surgery. J Clin Anesth. 45:51.</li>
	<li>Vora MU, Nicholas TA, Kassel CA, Grant SA. (2016). Adductor Canal Block for Knee Surgical Procedures: Review Article. J Clin Anesth. 35:295-303.</li>
	<li>Koşucu M, Beşir A, Eroğlu A, et al. (2013). Peripheral Nerve Block to the Lower Extremity Despite Relative Contraindication (Two Cases). Journal of Anesthesiology and Clinical Science. 2(1):29.</li>
	<li>Chang A, Dua A, Singh K, White BA. (2022). Peripheral Nerve Blocks. StatPearls, NCBI Bookshelf. Peripheral Nerve Blocks-StatPearls. Available at: <a href="http://www.ncbi.nlm.nih.gov/books/NBK459210">www.ncbi.nlm.nih.gov/books/NBK459210</a>.</li>
	<li>Amundson AW, Johnson RL. Adductor canal block procedure guide. In Maniker R, Crowley M, editors. USA: UpToDate. Available at: <a href="https://www.uptodate.com/contents/adductor-canal-block-procedure-guide/contributors">https://www.uptodate.com/contents/adductor-canal-block-procedure-guide/contributors</a>.</li>
	<li>Saad AH, El-Rab NAG, Aly MG, Said HG, et al. (2018). Review Article: Ultrasound-Guided Adductor Canal Block for Post-Operative Analgesia in Knee Arthroscopy. Med J Cairo Univ. 86(9):2141-2148.</li>
	<li>Sun C, Zhang X, Song F, Zhao Z, Du R, Wu S, et al. (2020). Is continuous catheter adductor canal block better than single-shot canal adductor canal block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis. Medicine (Baltimore). 99(20):e20320.</li>
</ol>

                    [full_text] => <p><sup>1</sup>Specialist Anesthesiologist, Tawam Hospital, UAE</p>

<p><sup>2</sup>Vedhasaya Pain and Spine Center, Ahmedabad, India</p>

<p><strong>*Corresponding author:</strong> Girishkumar Modi, Specialist Anesthesiologist, Tawam Hospital, UAE, Email: <a href="mailto:girishmodi75@gmail.com">girishmodi75@gmail.com</a>.</p>

<p><strong>Received Date:</strong> July 13, 2023</p>

<p><strong>Published Date:</strong> July 26, 2023</p>

<p><strong>Citation:</strong> Modi G, et al. (2023). The Adductor Canal Nerve Block: A Simple and Effective Approach for Knee Pain. Mathews J Anesth. 4(2):13.</p>

<p><strong>Copyrights:</strong> Modi G, et al. &copy; (2023).</p>

<p><strong>INTRODUCTION</strong></p>

<p>The Adductor Canal, also known as the Hunter Canal, is 8 to 14 cm long and located at the distal two-thirds of the medial thigh. It travels from the apex of the femoral triangle to the adductor hiatus, an aperture in the adductor magnus muscle. The vastus medialis forms the lateral border of the canal, the sartorius forms the medial border, and the adductor longus and magnus muscles form the base. It carries an important structure (saphenous nerve, superficial femoral artery and vein, vastus medialis muscle nerve, and obturator nerve branch) [1] (Figure 1 &amp; 2).</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg1.png" style="height:454px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 1.</strong> Adductor canal Anatomy through the sagittal section of the thigh. Downloaded from <a href="https://en.wikipedia.org/wiki/Adductor_canal#/media/File:Adductor_canal.png">https://en.wikipedia.org/wiki/Adductor_canal#/media/File:Adductor_canal.png</a></p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg2.png" style="height:650px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 2. </strong>Structures Contained within The Adductor Canal.</p>

<p>In ACNB, we focused on the saphenous nerve, a sensory leading branch of the femoral nerve that supply the skin of the medial, posteromedial, and anteromedial aspects of the lower leg from the distal thigh to the medial malleolus [2]. The main advantage of a saphenous nerve block over a femoral nerve block is that it causes less muscle weakness while providing comparable pain control. This means that, when compared to a femoral nerve block [3], it retains quadriceps motor strength and promotes early mobilization. It splits off from the femoral nerve in the upper third of the thigh, goes down next to the femoral sheath in the adductor canal, crosses in front of the femoral artery, and comes out of the canal with the saphenous branch of the descending genicular artery.</p>

<p>ACNB is used to provide anesthesia and analgesia for knee, medial lower leg, and ankle surgery [4]. It is an alternative approach to femoral nerve block for pain control after various knee procedures, especially knee arthroplasty and arthroscopy [5]. It is quite easy and simple to perform by injecting LA agent deep into the sartorius muscle in the adductor canal, and it is a reliable nerve block in terms of pain relief.</p>

<p>Absolute contraindications for nerve blocks include patient refusal, an allergy to Local Anesthetic (LA) agents, and an infection or contamination at the point of injection. Relative contraindications include coagulopathy and neuropathy [6]. However, it is important for patients to understand the procedure, its benefits, and its potential risks before consenting to a nerve block. Patients should be aware that while nerve blocks can provide effective pain relief, there is a small risk of complications such as nerve damage or infection [7]. Standard fasting recommendations ought to be adhered to, just like general anesthesia. Additionally, obtaining intravenous access is necessary because of the potential for adverse effects like vasovagal syncope and local anesthetic toxicity [7].</p>

<p>Apply standard monitoring in accordance with AAGBI guideline, and keep emergency drugs and an airway trolley on hand to handle any potential local anesthetic toxicity [8]. The patient will lie supine with the leg slightly abducted and externally rotated. The most suitable place for the provider to stand is on the same side of the nerve block and adjusts the patient&rsquo;s bed height as per the provider&#39;s comfort.</p>

<p>Turn on the ultrasound machine and tweak the controls to suit your needs (e.g., depth, gain, and focus). Skin disinfectant should be used to clean the area around the adductor canal nerve block site (typically the medial aspect of the knee) to prevent infection. After applying sterile ultrasound gel, the high-frequency linear probe is positioned transversely perpendicular to the long axis of the leg, just above the medial aspect of the knee, where the saphenous nerve is anticipated to be (Figure 3 &amp; 4).</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg3.png" style="height:466px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 3.</strong> Ultrasound image of the Adductor canal Nerve block.</p>

<p style="text-align:center"><img alt="" src="/userfiles/images/Anesthesia/Figg4.png" style="height:444px; width:600px" /></p>

<p style="text-align:center"><strong>Figure 4. </strong>Local anesthetic agent infiltration around the saphenous nerve under USG.</p>

<p>As you scan, you should see several structures, including adductor magnus, vastus medialis, sartorius, and the adductor canal. The Adductor canal is triangular space between these muscles, situated beneath the sartorius muscle. Therefore, it is also called Sub-Sartorial canal.</p>

<p>The saphenous nerve is located within the adductor canal, and it runs adjacent to the adductor longus muscle and the femoral artery. The saphenous nerve is visible as an oval or circular hypoechoic (darker) structure close to the femoral artery; use color doppler to identify the artery if required. After identifying the saphenous nerve, switch the ultrasound probe to the long-axis view to guide needle insertion. After local infiltration at site of injection, insert an 80 mm or 100 mm pujunk needle in an in-plane approach with the ultrasound going from the lateral to the medial side of the thigh. Advance the needle tip just lateral to the femoral artery and underneath to the sartorius muscle. After correct needle placement next to the saphenous nerve after piercing vaso-adductor membrane, a negative aspiration is performed to prevent arterial injection. Inject the local anesthetic (0.5 % ropivacaine, 15-20 ml) incrementally around the saphenous nerve, ensuring that the LA agent spreads to completely cover the nerve [2,9]. Finally, remove the needle and apply gentle pressure and a sterile dressing to the injection site. The patient should experience sensory loss in the medial leg and foot following the block. This block can be performed both pre- and post-operatively. Following the procedure, it is critical to monitor the patient&#39;s vitals and look for any complications.</p>

<p>Complications of adductor canal nerve blocks include nerve injury, which can cause temporary or permanent sensory or motor deficits in the affected area, infection, bleeding, or hematoma, allergic reactions, local anesthetic toxicity, and block failure [8].</p>

<p>Adductor canal nerve block can be given continuously using a catheter or as a single shot. Some studies have compared the clinical outcomes of continuous adductor canal block (C-ACB) and Single shot adductor canal block (SACB) after TKA. A meta-analysis of 8 randomized controlled trials involving 702 knees found that C-ACB can achieve better postoperative pain relief at 24 and 48 hours both at rest and after mobilization, a lower amount of opioid consumption at 72 hours, a shorter length of hospital stay, and a larger range of motion than SACB [10]. However, there was no discernible finding among the two methods in terms of quadriceps strength, mobility, and incidence of complications.</p>

<p>To summarize, the adductor canal nerve block is a straightforward, quick, and simple procedure. ACNB represent a novel and efficient form of nerve block that targets the saphenous nerve, a sensory branch of the femoral nerve at the mid-thigh level in the adductor canal for post-operative pain management, particularly in knee surgeries (Knee arthroplasty, knee arthroscopy, and ligament repairs) and assists the patient in early mobilization by preserving quadriceps muscle strength.</p>

<p><strong>ABBREVIATION</strong></p>

<p>ACNB: Adductor Canal Nerve Block; LA: Local Anesthetic; USG: Ultrasonography; C-ACB: Continuous Adductor Canal Block; SACB: Single Shot Adductor Canal Block.</p>

<p><strong>CONFLICT OF INTEREST</strong></p>

<p>None.</p>

<p><strong>FUNDING</strong></p>

<p>None.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Steven LO, Barrington M. (2023). Anatomy for the Adductor Canal Block: Does Location Really Matter? Anesth Analg. 136(3):455-457.</li>
	<li>Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R. (2009). Feasibility, and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med. 34(6):578-580.</li>
	<li>El-Ghandour AM, Mohamed AS, Abosief EMK, El‑Fattah Ghoneim MMA, Ahmad AHM, et al. (2022). Saphenous Nerve Block Versus Femoral Nerve Block in Enhanced Recovery After Knee Replacement Surgery Under Spinal Anaesthesia. Ain-Shams Journal of Anesthesiology. 14(1):56.</li>
	<li>Serkan T, Selvi O. (2018). Ultrasound Guided Distal Adductor Canal Block Provides Effective Postoperative Analgesia in Lower Leg Surgery. J Clin Anesth. 45:51.</li>
	<li>Vora MU, Nicholas TA, Kassel CA, Grant SA. (2016). Adductor Canal Block for Knee Surgical Procedures: Review Article. J Clin Anesth. 35:295-303.</li>
	<li>Koşucu M, Beşir A, Eroğlu A, et al. (2013). Peripheral Nerve Block to the Lower Extremity Despite Relative Contraindication (Two Cases). Journal of Anesthesiology and Clinical Science. 2(1):29.</li>
	<li>Chang A, Dua A, Singh K, White BA. (2022). Peripheral Nerve Blocks. StatPearls, NCBI Bookshelf. Peripheral Nerve Blocks-StatPearls. Available at: <a href="http://www.ncbi.nlm.nih.gov/books/NBK459210">www.ncbi.nlm.nih.gov/books/NBK459210</a>.</li>
	<li>Amundson AW, Johnson RL. Adductor canal block procedure guide. In Maniker R, Crowley M, editors. USA: UpToDate. Available at: <a href="https://www.uptodate.com/contents/adductor-canal-block-procedure-guide/contributors">https://www.uptodate.com/contents/adductor-canal-block-procedure-guide/contributors</a>.</li>
	<li>Saad AH, El-Rab NAG, Aly MG, Said HG, et al. (2018). Review Article: Ultrasound-Guided Adductor Canal Block for Post-Operative Analgesia in Knee Arthroscopy. Med J Cairo Univ. 86(9):2141-2148.</li>
	<li>Sun C, Zhang X, Song F, Zhao Z, Du R, Wu S, et al. (2020). Is continuous catheter adductor canal block better than single-shot canal adductor canal block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis. Medicine (Baltimore). 99(20):e20320.</li>
</ol>

                    [sm_link] => 
                    [published_dt] => 26-07-2023
                    [vol_name] => Volume 4
                    [vol_year] => 2023
                    [issue] => 2
                    [issue_status] => 3
                    [j_name] => Mathews Journal of Anesthesia
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_page_url] => anesthesia
                )

            [4] => stdClass Object
                (
                    [fixed_date] => 2023-06-12
                    [id] => 772
                    [title] => Myocarditis in a Patient with Diabetic Ketoacidosis: A Case Report
                    [type] => Case Report
                    [page_url] => myocarditis-in-a-patient-with-diabetic-ketoacidosis-a-case-report
                    [vol_id] => 174
                    [issue_id] => 232
                    [image] => myocarditis-in-a-patient-with-diabetic-ketoacidosis-a-case-report.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Fatima Saeed*, Geetanjali Gupta, Ayesha Javaid</strong></p>

                    [about] => <p>Saeed F, et al. (2023). Myocarditis in a Patient with Diabetic Ketoacidosis: A Case Report. Mathews J Anesth. 4(1):12.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p>Manchester Royal Infirmary, England</p>

<p><strong>*Corresponding author:</strong> Dr. Fatima Saeed, Manchester Royal Infirmary, England, Tel: 07375737352, Email: <a href="mailto:fatima.saeed@mft.nhs.uk">fatima.saeed@mft.nhs.uk</a>.</p>

<p><strong>Received Date:</strong> May 20, 2023</p>

<p><strong>Published Date:</strong> June 12, 2023</p>

<p><strong>Citation:</strong> Saeed F, et al. (2023). Myocarditis in a Patient with Diabetic Ketoacidosis: A Case Report. Mathews J Anesth. 4(1):12.</p>

<p><strong>Copyrights:</strong> Saeed F, et al. &copy; (2023).</p>

<p><strong>ABSTRACT</strong></p>

<p>A case of diabetic ketoacidosis (DKA) complicated by acute myocarditis, which was confirmed by Cardiac MRI. A 27-year-old man with diagnosed type 1 diabetes mellitus was hospitalized with severe DKA, blood sugar on admission was 69.3mmol/l and Hba1c was 104 mmol/mol. The initial ECG showed no acute changes however later he developed ST-T changes on his ECG associated with a significant troponin rise which raised the possibility of Myocarditis. The coronary angiogram ruled out any coronary artery disease, however the diagnosis of Myopericarditis was confirmed based on the echocardiogram findings and cardiac MRI. Viruses are the most common causative agents of myocarditis, our patient described symptoms of fatigue that might indicate the probable underlying viral infection however the excessive alcohol intake and non-compliance with insulin were the contributing factors towards development of diabetic ketoacidosis. The whole viral screen including parvovirus and covid-19 was negative. The Epstein bar virus (EBV) although weekly positive, with minimal viral load couldn&rsquo;t account for the patient&rsquo;s symptoms. Another rare condition that can present with myocarditis is fulminant type 1 diabetes mellitus, which is believed to be non-immune condition causing rapid onset of diabetes mellitus, the exact aetiology is still uncertain, but the presence of islet injury accompanied by myocardial inflammation points towards underlying viral infection as the cause of sudden onset of diabetes mellitus. The auto antibodies for Type 1 DM turn out to be negative in these cases, however in our patient they weren&rsquo;t done because he was a confirmed Type 1 Diabetic. The patient successfully responded to the symptomatic treatment for DKA, implicating that severe DKA was the cause of myocarditis. He was provided education on Type 1 diabetes mellitus and subsequently discharged without any further complications with future outpatient appointment in cardiology clinic.</p>

<p><strong>Keywords</strong>: Myocarditis, Diabetic Ketoacidosis, Fulminant Type 1 Diabetes.</p>

                    [full_text] => <p>Manchester Royal Infirmary, England</p>

<p><strong>*Corresponding author:</strong> Dr. Fatima Saeed, Manchester Royal Infirmary, England, Tel: 07375737352, Email: <a href="mailto:fatima.saeed@mft.nhs.uk">fatima.saeed@mft.nhs.uk</a>.</p>

<p><strong>Received Date:</strong> May 20, 2023</p>

<p><strong>Published Date:</strong> June 12, 2023</p>

<p><strong>Citation:</strong> Saeed F, et al. (2023). Myocarditis in a Patient with Diabetic Ketoacidosis: A Case Report. Mathews J Anesth. 4(1):12.</p>

<p><strong>Copyrights:</strong> Saeed F, et al. &copy; (2023).</p>

<p><strong>ABSTRACT</strong></p>

<p>A case of diabetic ketoacidosis (DKA) complicated by acute myocarditis, which was confirmed by Cardiac MRI. A 27-year-old man with diagnosed type 1 diabetes mellitus was hospitalized with severe DKA, blood sugar on admission was 69.3mmol/l and Hba1c was 104 mmol/mol. The initial ECG showed no acute changes however later he developed ST-T changes on his ECG associated with a significant troponin rise which raised the possibility of Myocarditis. The coronary angiogram ruled out any coronary artery disease, however the diagnosis of Myopericarditis was confirmed based on the echocardiogram findings and cardiac MRI. Viruses are the most common causative agents of myocarditis, our patient described symptoms of fatigue that might indicate the probable underlying viral infection however the excessive alcohol intake and non-compliance with insulin were the contributing factors towards development of diabetic ketoacidosis. The whole viral screen including parvovirus and covid-19 was negative. The Epstein bar virus (EBV) although weekly positive, with minimal viral load couldn&rsquo;t account for the patient&rsquo;s symptoms. Another rare condition that can present with myocarditis is fulminant type 1 diabetes mellitus, which is believed to be non-immune condition causing rapid onset of diabetes mellitus, the exact aetiology is still uncertain, but the presence of islet injury accompanied by myocardial inflammation points towards underlying viral infection as the cause of sudden onset of diabetes mellitus. The auto antibodies for Type 1 DM turn out to be negative in these cases, however in our patient they weren&rsquo;t done because he was a confirmed Type 1 Diabetic. The patient successfully responded to the symptomatic treatment for DKA, implicating that severe DKA was the cause of myocarditis. He was provided education on Type 1 diabetes mellitus and subsequently discharged without any further complications with future outpatient appointment in cardiology clinic.</p>

<p><strong>Keywords</strong>: Myocarditis, Diabetic Ketoacidosis, Fulminant Type 1 Diabetes.</p>

<p><strong>ABBREVIATIONS</strong></p>

<p>DKA: Diabetic Ketoacidosis; EBV: Epstein Bar Virus; ECG: Electrocardiogram; ACS: Acute Coronary Syndrome; CMR: Cardiac Magnetic Resonance; CR: Creatinine; UR: Urea.</p>

<p><strong>INTRODUCTION</strong></p>

<p>Diabetic ketoacidosis (DKA) is a common presentation patients with uncontrolled type 1 DM. Patients presenting with DKA can have subtle ECG changes that include non-specific ST-T changes which resolve after treatment of the acidosis [1]. The ECG changes usually appear within 24 hours of DKA most common is ST segment depression, although there maybe T wave inversions and prolongation of the QT interval [2], sometimes attributed to be secondary to a viral infection.</p>

<p>A rare case of severe diabetic ketoacidosis complicated by myocarditis is described below.</p>

<p>Written signed consent was obtained from the patient.</p>

<p><strong>CASE DESCRIPTION</strong></p>

<p>A 27-year-old male known to have type 1 diabetes mellitus was admitted with vomiting, lethargy, polydipsia, and shortness of breath after a weekend of binge drinking of alcohol. He described that he was feeling unwell for the last few days, had been non-compliant with his insulin for the last few days and had a binge of alcohol for the last few days before presenting to the hospital. He had recently moved to new city and was non-compliant with his insulin. He denied having any other significant past medical history. He was non-smoker, had alcohol consumption of 16 units on average per week with occasional binges on weekends, he denied illicit drug use.</p>

<p>On examination he was a slim looking guy, having Kussmaul breathing, appeared tired and dehydrated. He was found to be acidotic, blood glucose (69.3 mmol/l), high ketones (6+) and was found to be in acute kidney injury, AKI- stage 3 with creatinine of 262 umol/L and eGFR of 28 mL/min/l.73m<sup>2</sup>, diagnosed with diabetic ketoacidosis (DKA) with acute kidney injury. He was immediately started on treatment as per Joint British Diabetes Societies guideline for DKA, he responded well to the treatment. His AKI started to improve with fluid resuscitation, and intravenous insulin.</p>

<p>On Day 2 of admission on the medical ward, he developed severe epigastric pain associated with burning pain radiating to the upper chest. He was given omeprazole and liquid sodium alginate with calcium carbonate and sodium bicarbonate for suspected dyspeptic symptom, his ECG showed ST segment elevation in leads V2-V6. ECG attached below, ECG on admission showed normal sinus rhyhm.Serial troponins were 99 ng/L and 758 ng/L respectively. Patient was subsequently moved from the medical ward to the cardiology ward and started on treatment for acute coronary syndrome (ACS) in view of new ST-T changes and acute troponin rise. He had the trans-thoracic echocardiogram done which showed severe LVSD with EF of 30%. His coronary angiogram revealed normal coronary arteries with no evidence of obstruction or stenosis therefore the ACS treatment was stopped. Subsequently the diagnosis of probable myocarditis was made pending cardiac magnetic resonance angiogram (CMR). All the viral serology, autoimmune and vasculitis screen was negative. Pending cardiac MRI patient self-discharged from the hospital understanding the risks and consequences with the prescription of colchcine,beta blocker and ACE inhibitor.</p>

<p>However, two days later he re-presented to the emergency department with chest pain got re-admitted at that time his troponin was 239 ng/L. The cardiac magnetic resonance (CMR) showed finding of myopericarditis with mild and apical subendocardial necrosis suggestive of ongoing inflammation, normal left ventricle geometry and function. No significant valve disease, small bilateral pleural effusions, which confirmed the diagnosis of Myopericarditis. The left ventricle size and function had improved compared to the echocardiogram before indicative of rapid and complete recovery He was started on Ace inhibitor, beta blocker, colchicine, basal bolus insulin regime with short acting Novorapid insulin TDS and long-acting Lantus insulin OD. His troponin had reduced to 19 ng/L and the AKI had resolved, the graph below shows the trend of the troponin, and he was then discharged, to be followed up in the heart Failure clinic and diabetes outpatient clinic.</p>

<p><strong>Investigations</strong></p>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Ref. Range</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result Date</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">262</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202108:53</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">262</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202108:41</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">262</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202108:43</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">111</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202100:44</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">88</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202112:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">75</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202123:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">61</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202120:23</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">64</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202111:59</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">66</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">01-May-202117:14</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">62</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">02-May-202108:25</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">55</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-May-202110:08</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">55</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 -104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-May-202110:06</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Creatinine (CR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">74</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">umol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">59 - 104</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">05-May-202109:40</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/CR.png" style="height:291px; width:600px" /></div>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Ref. Range</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result Date</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">19.5</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-20210S:43</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">19.5</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-20210S:53</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">19.5</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-20210S:41</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">11.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202100:44</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">7.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202112:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.9</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202123:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202120:23</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202111:59</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">4</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">01-May-202117:14</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">02-May-20210S:25</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-May-202110:0S</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-May-202110:06</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Urea (UR)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.4</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">2.5 - 7.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">05-May-202109:40</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/UREA.png" style="height:291px; width:600px" /></div>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result Date</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">28</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-04-2021 07:37</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">78</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-04-2021 07:37</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;90</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-04-2021 07:37</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;90</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">01-05-2021 16:07</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;90</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">02-05-2021 06:27</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;90</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-05-2021 07:17</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">eGFR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;90</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mL/min/l.73m A2</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">05-05-2021 06:29</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/eGFR.png" style="height:269px; width:600px" /></div>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Ref. Range</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result Date</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;41.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-04-2021 07:32</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;41.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-04-2021 09:32</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">&gt;41.6</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202111:55</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">30.7</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202114:40</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">11.9</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202119:31</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">12.1</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">26-Apr-202123:52</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">6.4</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202108:41</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Glucose</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">4.8</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">mmol/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">3.6 - 5.3</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202122:46</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/Blood%20Glu.png" style="height:302px; width:600px" /></div>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Ref. Range</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result Date</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">99</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202112:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin-T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">758</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202114:50</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">758</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202115:52</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">1535</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">27-Apr-202123:33</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin-T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">850</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202120:23</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">1014</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">29-Apr-202111:59</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin-T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">239</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">01-May-202117:14</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">150</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">02-May-202108:25</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin-T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">39</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">03-May-202110:08</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Troponin- T (TNT)</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">19</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">ng/L</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">0-14</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">05-May-202109:40</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/FIGURE-1.png" style="height:361px; width:600px" /></div>

<p style="text-align: center;"><strong>FIGURE-1</strong></p>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Virology + Other Investigations</strong></p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;"><strong>Result</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">SARS-CoV-2 RNA</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not deteceted</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Parvovirus B19 DNA</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">EBV PCR</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Positive at the limit of sensitivity of the test</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">CMV DNA</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Influenze A Virus</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Influenza B Virus</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Respiratory Syncytial Virus</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">HIV 1+2 Antibody</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">P24 Antigen</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Not Detected</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Blood Culture</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">No Growth</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Chest X-Ray</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">No Acute Pulmonary features</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p style="text-align: center;">Blood Film</p>
			</td>
			<td style="height:20px">
			<p style="text-align: center;">Neutrophils show toxic granulation. Monocytes activated.</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear:both;">&nbsp;</div>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td style="height:20px">
			<p><strong>Test</strong></p>
			</td>
			<td style="height:20px">
			<p><strong>Result</strong></p>
			</td>
			<td style="height:20px">
			<p><strong>UoM</strong></p>
			</td>
			<td style="height:20px">
			<p><strong>Ref. Range</strong></p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>White Blood Cells (WBC)</p>
			</td>
			<td style="height:20px">
			<p>35.6</p>
			</td>
			<td style="height:20px">
			<p>x10^9/L</p>
			</td>
			<td style="height:20px">
			<p>4.0 -11.0</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Red Blood Cells (RBC)</p>
			</td>
			<td style="height:20px">
			<p>5.65</p>
			</td>
			<td style="height:20px">
			<p>x10^12/L</p>
			</td>
			<td style="height:20px">
			<p>4.50 - 6.00</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Haemoglobin (HB)</p>
			</td>
			<td style="height:20px">
			<p>163</p>
			</td>
			<td style="height:20px">
			<p>g/L</p>
			</td>
			<td style="height:20px">
			<p>130 -180</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Haematocrit (HCT)</p>
			</td>
			<td style="height:20px">
			<p>0.495</p>
			</td>
			<td style="height:20px">
			<p>Ratio</p>
			</td>
			<td style="height:20px">
			<p>0.400 - 0.520</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Mean Cell Volume</p>
			</td>
			<td style="height:20px">
			<p>88</p>
			</td>
			<td style="height:20px">
			<p>fl</p>
			</td>
			<td style="height:20px">
			<p>80 - 98</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Mean Cell Haemoglobin</p>
			</td>
			<td style="height:20px">
			<p>28.8</p>
			</td>
			<td style="height:20px">
			<p>pg</p>
			</td>
			<td style="height:20px">
			<p>27.0 - 33.0</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Mean Cell Haemoglobin</p>
			</td>
			<td style="height:20px">
			<p>329</p>
			</td>
			<td style="height:20px">
			<p>g/L</p>
			</td>
			<td style="height:20px">
			<p>320 - 365</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Platelets (PLT)</p>
			</td>
			<td style="height:20px">
			<p>375</p>
			</td>
			<td style="height:20px">
			<p>x10^9/L</p>
			</td>
			<td style="height:20px">
			<p>150 - 400</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Film (FM)</p>
			</td>
			<td style="height:20px">
			<p>Film Prepared</p>
			</td>
			<td style="height:20px">&nbsp;</td>
			<td style="height:20px">&nbsp;</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Neutrophils (NEUT)</p>
			</td>
			<td style="height:20px">
			<p>30.97</p>
			</td>
			<td style="height:20px">
			<p>x10^9/L</p>
			</td>
			<td style="height:20px">
			<p>1.80 -7.50</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Lymphocytes (LYMPH)</p>
			</td>
			<td style="height:20px">
			<p>2.85</p>
			</td>
			<td style="height:20px">
			<p>xlO^9/L</p>
			</td>
			<td style="height:20px">
			<p>.1.00 - 4.00</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Monocytes (MONO)</p>
			</td>
			<td style="height:20px">
			<p>1.78</p>
			</td>
			<td style="height:20px">
			<p>x10^9/L</p>
			</td>
			<td style="height:20px">
			<p>. 0.20 -1.00</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>ESR</p>
			</td>
			<td style="height:20px">
			<p>10</p>
			</td>
			<td style="height:20px">
			<p>Mm/1st Hr</p>
			</td>
			<td style="height:20px">
			<p>0-5</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Alanine Transaminase</p>
			</td>
			<td style="height:20px">
			<p>18</p>
			</td>
			<td style="height:20px">
			<p>Iu/L</p>
			</td>
			<td style="height:20px">
			<p>Jan-50</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Alkaline Phosphatase</p>
			</td>
			<td style="height:20px">
			<p>160</p>
			</td>
			<td style="height:20px">
			<p>U/L</p>
			</td>
			<td style="height:20px">
			<p>30 -130</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Total Protein (TP)</p>
			</td>
			<td style="height:20px">
			<p>77</p>
			</td>
			<td style="height:20px">
			<p>g/L</p>
			</td>
			<td style="height:20px">
			<p>60 - 80</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Albumin (ALB)</p>
			</td>
			<td style="height:20px">
			<p>44</p>
			</td>
			<td style="height:20px">
			<p>g/L</p>
			</td>
			<td style="height:20px">
			<p>34 - 48</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Bilirubin (TBIL)</p>
			</td>
			<td style="height:20px">
			<p>8</p>
			</td>
			<td style="height:20px">
			<p>umol/L</p>
			</td>
			<td style="height:20px">
			<p>0-21</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>CRP</p>
			</td>
			<td style="height:20px">
			<p>38</p>
			</td>
			<td style="height:20px">
			<p>mg/L</p>
			</td>
			<td style="height:20px">
			<p>0-5</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Ttg Iga Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.5</p>
			</td>
			<td style="height:20px">
			<p>kU/L</p>
			</td>
			<td style="height:20px">
			<p>0-14.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Ss-A Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Ss-AS2 Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Ss-A60 Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>55-8 Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Rnp 68</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Anti Sm</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Smrnp Antibody</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9 &#39;</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Ribosomal P</p>
			</td>
			<td style="height:20px">
			<p>0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Chromatin</p>
			</td>
			<td style="height:20px">
			<p>0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Jo~1</p>
			</td>
			<td style="height:20px">
			<p>0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>ScI-70</p>
			</td>
			<td style="height:20px">
			<p>0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-1.6</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Antinuclear Ab</p>
			</td>
			<td style="height:20px">
			<p>Negative</p>
			</td>
			<td style="height:20px">&nbsp;</td>
			<td style="height:20px">&nbsp;</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Centromere</p>
			</td>
			<td style="height:20px">
			<p>&lt;0.2</p>
			</td>
			<td style="height:20px">
			<p>AI</p>
			</td>
			<td style="height:20px">
			<p>0-0.9</p>
			</td>
		</tr>
		<tr>
			<td style="height:20px">
			<p>Igg Ds-Dna Ab</p>
			</td>
			<td style="height:20px">
			<p>&lt;1.0</p>
			</td>
			<td style="height:20px">
			<p>IU/ML</p>
			</td>
			<td style="height:20px">
			<p>0-9.9</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear:both;">&nbsp;</div>

<p><strong>SERIAL ECGs</strong></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/SERIAL%20ECGs1.png" style="height:427px; width:600px" /></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/SERIAL%20ECGs2.png" style="height:453px; width:600px" /></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/SERIAL%20ECGs3.png" style="height:438px; width:600px" /></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/SERIAL%20ECGs4.png" style="height:429px; width:600px" /></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/FIGURE-2.png" style="height:440px; width:600px" /></p>

<p style="text-align: center;"><strong>FIGURE-2</strong></p>

<p><strong>CARDIAC MAGNETIC RESONANCE REPORT</strong></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/FIGURE-3_1.png" style="height:614px; width:615px" /></p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/FIGURE-3_2.png" style="height:538px; width:600px" /></p>

<p style="text-align: center;"><strong>FIGURE-3</strong></p>

<p><strong>DISCUSSION</strong></p>

<p>Myopericarditis is an inflammatory condition of the heart muscle and pericardium caused by various bacteria and viruses such as coxsackie viruses, adenovirus, and parvovirus B19 are the common causes, other viruses also cause myocarditis, such as parainfluenza and COVID-19 [3]. The exact aetiology is unknown. Multiple mechanisms are proposed. The pathogenesis of viral myocarditis is associated with direct damage to the myocardium and immune-mediated cardiac muscle damage after a viral infection, and the cytokine response is essential to cause immune-mediated myocyte damage [3]. Myocarditis in adults with DKA is rarely reported however there are a few cases of myocarditis with DKA reported in children [4]. The aetiology proposed in children was that acidosis might affect the contractility of the cardiac muscle at the cellular level [4].</p>

<p>The usual ECG findings of acute myocarditis are inverted, flat, or biphasic T waves and S-T elevation, but it doesn&rsquo;t involve the QRS [2].</p>

<p>The ECG changes in our patient couldn&rsquo;t be explained by the electrolyte abnormalities as all the electrolytes including the phosphate were normal. Low phosphate should be considered as cause of unexplained ECG changes in patients with DKA as hypophosphatemia may play a role in the insufficient cardiac output but does not explain the ST segment elevation or the cardiac MRI findings in our patient [5].</p>

<p>Another rare condition which presents with rapid onset of diabetes as DKA with myocarditis is fulminant type 1 DM. Fulminant type 1 diabetes is relatively new subtype of diabetes which presented with a rapid onset of symptoms, due to complete destruction of pancreatic beta cells, absent auto antibodies, and increased level of pancreatic enzymes in the serum. The exact mechanism of the beta cell destruction isn&rsquo;t known but an underlying viral infection was proposed to be the likely cause as evidence by mononuclear cell infiltrations, detected in endocrine and exocrine pancreas [6]. The diagnosis of fulminant type 1 DM is made by absent autoantibodies, low HBA1C, low C peptide and urinary C peptide levels. Patients presenting with fulminant type 1 DM have a high mortality [7] therefore that should be considered a differential diagnosis in a patient presenting with new onset DKA and non-specific ECG changes which could point to the myocarditis. Our patient however didn&rsquo;t fulfil the criteria for fulminant type 1 DM and weakly positive EBV serology didn&rsquo;t explain the myocarditis.</p>

<p>The incidence of Myocarditis is 12% in adults [8], but no cases of DKA and myocarditis have been reported in literature in adults so far. There have been case reports of DKA with myocarditis in children [9].</p>

<p>The complications of Myocarditis can lead to dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and heart failure [8] therefore it is very important to make early diagnosis and manage accordingly.</p>

<p><strong>CONCLUSION</strong></p>

<p>We report a case of myocarditis in a patient with diabetic ketoacidosis. It is important to consider other aetiologies in any patient who presented with DKA and found to have unexplained an ECG change that is fulminant type 1 DM or electrolyte abnormalities which were ruled out in our case. Cardiac MRI remains an important non-invasive tool to diagnose myocarditis.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Mokuno T, Sawai Y, Oda N, Mano T, Hayakawa N, Kato R, et al. (1996). A case of myocarditis associated with IDDM. Diabetes Care. 19(4):374-378.</li>
	<li>Gibbs P. (1974). Three cases of acute ketotic diabetes mellitus with myocarditis: a common viral origin? Br Med J. 3(5934):781-783.</li>
	<li>Ohara N, Kaneko M, Kuwano H, Ebe K, Fujita T, Nagai T, et al. (2015). Fulminant Type 1 Diabetes Mellitus and Fulminant Viral Myocarditis.&nbsp;International heart journal. 56(2):239-244.</li>
	<li>Halloum A, Al Neyadi S. (2019). Myocardial dysfunction associated with diabetic ketoacidosis in a 5-year-old girl. SAGE Open Med Case Rep. 7:2050313X19847797.</li>
	<li>Hiramatsu S, Komori K, Mori E, Ogo A, Maruyama S, Kato S. (2011). A case of fulminant type 1 diabetes mellitus accompanied by myocarditis. Endocr J. 58(7):553-557.</li>
	<li>Makino K, Nishimae I, Suzuki N, Nitta S, Saitoh H, Kasao M, et al. (2013). Myocarditis with fulminant type 1 diabetes mellitus diagnosed by cardiovascular magnetic resonance imaging: a case report. BMC Res Notes. 6:347.</li>
	<li>Kinoshita T, Kaneto H, Kawasaki F, Anno T, Kurihara T, Yamada H, et al. (2018). Fulminant Type 1 Diabetes Mellitus Complicated with a Life-threatening Electrolyte Abnormality and Abnormal Electrocardiogram Findings. Intern Med. 57(18):2685-2688.</li>
	<li>Zhang T, Miao W, Wang S, Wei M, Su G, Li Z. (2015). Acute myocarditis mimicking ST-elevation myocardial infarction: A case report and review of the literature. Exp Ther Med. 10(2):459-464.</li>
	<li>Abbas Q, Arbab S, Haque AU, Humayun KN. (2018). Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit. Pak J Med Sci. 34(1):106-109.</li>
</ol>

                    [sm_link] => 
                    [published_dt] => 12-06-2023
                    [vol_name] => Volume 4
                    [vol_year] => 2023
                    [issue] => 1
                    [issue_status] => 3
                    [j_name] => Mathews Journal of Anesthesia
                    [j_image] => mathews-journal-of-anesthesia1.jpg
                    [j_page_url] => anesthesia
                )

            [5] => stdClass Object
                (
                    [fixed_date] => 2023-03-28
                    [id] => 713
                    [title] => Prospective General Inhalation Anesthesia for Pediatric Patients Undergoing Radiotherapy. Pilot Project with 25 Children without Venous Access
                    [type] => Research Article
                    [page_url] => prospective-general-inhalation-anesthesia-for-pediatric-patients-undergoing-radiotherapy-pilot-project-with-25-children-without-venous-access
                    [vol_id] => 174
                    [issue_id] => 232
                    [image] => prospective-general-inhalation-anesthesia-for-pediatric-patients-undergoing-radiotherapy-pilot-project-with-25-children-without-venous-access.pdf
                    [author_type] => Authors
                    [author] => <p><strong>Luiz Eduardo Imbelloni<sup>1,</sup>*, D&eacute;bora Baroni<sup>2</sup>, Patr&iacute;cia L Proc&oacute;pio Lara<sup>3</sup>, Sylvio Valen&ccedil;a de Lemos Neto<sup>4</sup>, Ana Cristina Pinho<sup>5</sup>, Anna L&uacute;cia Cala&ccedil;a Rivoli<sup>6</sup>, </strong><strong>Geraldo Borges de Morais Filho<sup>7</sup></strong></p>

                    [about] => <p>Imbelloni LE, et al. (2023). Prospective General Inhalation Anesthesia for Pediatric Patients Undergoing Radiotherapy. Pilot Project with 25 Children without Venous Access. Mathews J Anesth. 4(1):11.</p>

                    [abstract_type] => Abstract
                    [abstracts] => <p><sup>1</sup>Senior Researcher of Nacional Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil</p>

<p><sup>2</sup>Resident of the 3rd year of Anesthesiology at INCA, Rio de Janeiro, RJ, Brazil</p>

<p><sup>3</sup>Anesthesiologist at the National Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil</p>

<p><sup>4</sup>Anesthesiologist at the National Cancer Institute (INCA), Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil</p>

<p><sup>5</sup>Anesthesiologist at the National Cancer Institute (INCA), Co-Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil</p>

<p><sup>6</sup>Anesthesiologist at the National Cancer Institute (INCA), Responsible Coreme Residence INCA</p>

<p><sup>7</sup>Master in Labour Economics, UFPB, Jo&atilde;o Pessoa-PB, Brazil &amp; Statistician of the Complexo Hospitalar Mangabeira, Jo&atilde;o Pessoa-PB, Brazil</p>

<p><strong>*Corresponding author: </strong>Luiz Eduardo Imbelloni, MD, PhD, Senior Researcher of Nacional Cancer Institute (INCA), Av. Epit&aacute;cio Pessoa, 2356/203-Lagoa, 22411-072-Rio de Janeiro, RJ, Brazil, Tel: + 55.11.99429-3637, ORCID ID: 0000-0003-3808-5858; Emails: <a href="mailto:dr.luiz.imbelloni@gmail.com">dr.luiz.imbelloni@gmail.com</a>; <a href="mailto:luiz.imbelloni@edu.inca.gov.br">luiz.imbelloni@edu.inca.gov.br</a>.</p>

<p><strong>Received Date:</strong> March 17, 2023</p>

<p><strong>Published Date:</strong> March 28, 2023</p>

<p><strong>Citation:</strong> Imbelloni LE, et al. (2023). Prospective General Inhalation Anesthesia for Pediatric Patients Undergoing Radiotherapy. Pilot Project with 25 Children without Venous Access. Mathews J Anesth. 4(1):11.</p>

<p><strong>Copyrights:</strong> Imbelloni LE, et al. &copy; (2023).</p>

<p><strong>ABSTRACT</strong></p>

<p><strong>Background</strong><strong>:</strong> Radiation therapy is a cornerstone in the treatment of cancer in children. Although painless, there is a requirement for the child to lie still by themselves in the radiation treatment room. Most RT services use intravenous sedation or anesthesia. The aim of the study was to describe the technique of inhalational anesthesia with sevoflurane without venoclysis for general anesthesia during RT from January to December 2022, as a pilot project in 25 children. <strong>Methods</strong>: It is an observational, descriptive, and prospective study of a series of cases. Pediatric patients aged 2 to 13 years diagnosed with cancer, underwent RT under sevoflurane anesthesia without venous access. RT is performed five days a week, with only Tuesdays selected, with the same anesthesiologist and anesthesia resident. patients were monitored with a cardioscope, pulse oximetry, capnography, and gas analyzer. During the procedure, the following were evaluated: the expired fraction of sevoflurane and the corresponding Minimum Alveolar Concentration (MAC) for induction and maintenance, anesthesia and awakening time, place and time of irradiation, and immediate and late adverse effects (after awakening until discharge hospital). Finally, the time of hospital discharge and complications were evaluated after completion. <strong>Results</strong>: A total of 25 patients diagnosed with cancer and receiving radiotherapy were studied. No difference was observed between genders, with 96% of children between 2 and 8 years old, and 60% being 4 and 5-year-old children. Sevoflurane was administered to 100.0% of patients in all treatment sessions. Mean anesthesia time was 22.96 minutes, mean irradiation time was 10.84 minutes, and mean awakening time was 6.12 minutes. Side effects were more frequent when they reached values greater than or equal to 1.5 MAC. <strong>Conclusions</strong>: In pediatric patients diagnosed with cancer, the use of sedation and anesthesia during radiotherapy treatment was required mainly in young children. Sevoflurane as monotherapy without venous access turned out to have no severe complications, however, sevoflurane MAC increases above 1.5 were associated with the onset of complications. The awakening was quick (6 minutes) as well as the discharge for residence (19 minutes).</p>

<p><strong>Keywords</strong>: Radiotherapy, Pediatric, Oncology treatment, Sevoflurane, Inhalation Anesthesia.</p>

                    [full_text] => <p><sup>1</sup>Senior Researcher of Nacional Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil</p>

<p><sup>2</sup>Resident of the 3rd year of Anesthesiology at INCA, Rio de Janeiro, RJ, Brazil</p>

<p><sup>3</sup>Anesthesiologist at the National Cancer Institute (INCA), Rio de Janeiro, RJ, Brazil</p>

<p><sup>4</sup>Anesthesiologist at the National Cancer Institute (INCA), Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil</p>

<p><sup>5</sup>Anesthesiologist at the National Cancer Institute (INCA), Co-Responsible for the CET-SBA of the National Cancer Institute, Rio de Janeiro, RJ, Brazil</p>

<p><sup>6</sup>Anesthesiologist at the National Cancer Institute (INCA), Responsible Coreme Residence INCA</p>

<p><sup>7</sup>Master in Labour Economics, UFPB, Jo&atilde;o Pessoa-PB, Brazil &amp; Statistician of the Complexo Hospitalar Mangabeira, Jo&atilde;o Pessoa-PB, Brazil</p>

<p><strong>*Corresponding author: </strong>Luiz Eduardo Imbelloni, MD, PhD, Senior Researcher of Nacional Cancer Institute (INCA), Av. Epit&aacute;cio Pessoa, 2356/203-Lagoa, 22411-072-Rio de Janeiro, RJ, Brazil, Tel: + 55.11.99429-3637, ORCID ID: 0000-0003-3808-5858; Emails: <a href="mailto:dr.luiz.imbelloni@gmail.com">dr.luiz.imbelloni@gmail.com</a>; <a href="mailto:luiz.imbelloni@edu.inca.gov.br">luiz.imbelloni@edu.inca.gov.br</a>.</p>

<p><strong>Received Date:</strong> March 17, 2023</p>

<p><strong>Published Date:</strong> March 28, 2023</p>

<p><strong>Citation:</strong> Imbelloni LE, et al. (2023). Prospective General Inhalation Anesthesia for Pediatric Patients Undergoing Radiotherapy. Pilot Project with 25 Children without Venous Access. Mathews J Anesth. 4(1):11.</p>

<p><strong>Copyrights:</strong> Imbelloni LE, et al. &copy; (2023).</p>

<p><strong>ABSTRACT</strong></p>

<p><strong>Background</strong><strong>:</strong> Radiation therapy is a cornerstone in the treatment of cancer in children. Although painless, there is a requirement for the child to lie still by themselves in the radiation treatment room. Most RT services use intravenous sedation or anesthesia. The aim of the study was to describe the technique of inhalational anesthesia with sevoflurane without venoclysis for general anesthesia during RT from January to December 2022, as a pilot project in 25 children. <strong>Methods</strong>: It is an observational, descriptive, and prospective study of a series of cases. Pediatric patients aged 2 to 13 years diagnosed with cancer, underwent RT under sevoflurane anesthesia without venous access. RT is performed five days a week, with only Tuesdays selected, with the same anesthesiologist and anesthesia resident. patients were monitored with a cardioscope, pulse oximetry, capnography, and gas analyzer. During the procedure, the following were evaluated: the expired fraction of sevoflurane and the corresponding Minimum Alveolar Concentration (MAC) for induction and maintenance, anesthesia and awakening time, place and time of irradiation, and immediate and late adverse effects (after awakening until discharge hospital). Finally, the time of hospital discharge and complications were evaluated after completion. <strong>Results</strong>: A total of 25 patients diagnosed with cancer and receiving radiotherapy were studied. No difference was observed between genders, with 96% of children between 2 and 8 years old, and 60% being 4 and 5-year-old children. Sevoflurane was administered to 100.0% of patients in all treatment sessions. Mean anesthesia time was 22.96 minutes, mean irradiation time was 10.84 minutes, and mean awakening time was 6.12 minutes. Side effects were more frequent when they reached values greater than or equal to 1.5 MAC. <strong>Conclusions</strong>: In pediatric patients diagnosed with cancer, the use of sedation and anesthesia during radiotherapy treatment was required mainly in young children. Sevoflurane as monotherapy without venous access turned out to have no severe complications, however, sevoflurane MAC increases above 1.5 were associated with the onset of complications. The awakening was quick (6 minutes) as well as the discharge for residence (19 minutes).</p>

<p><strong>Keywords</strong>: Radiotherapy, Pediatric, Oncology treatment, Sevoflurane, Inhalation Anesthesia.</p>

<p><strong><u>KEY POINTS</u></strong></p>

<div>
<p><strong>What is already known</strong>?</p>

<ul>
	<li>Radiotherapy (<strong>RT</strong>) is a fundamental part of cancer treatment in pediatric patients.</li>
	<li>Sedation and/or general anesthesia are commonly utilized to facilitate radiotherapy treatment in children.</li>
	<li>All intravenous drugs such as midazolam, propofol, ketamine, and dexmedetomidine were indicated for sedation anesthesia for the RT procedure.</li>
	<li>Propofol has become the drug of choice at various institutions.</li>
	<li>Few studies with inhaled agents have been published.</li>
	<li>Sevoflurane is an ether inhalation general anesthetic agent.</li>
</ul>

<p><strong>What this article adds.</strong></p>

<ul>
	<li>Prospective study with only one inhalational agent without venoclysis, and without tracheal intubation.</li>
	<li>Sevoflurane proved to be a fast-acting agent with smooth induction and awakening in around 6 minutes.</li>
	<li>There were few side effects during the procedure.</li>
	<li>None of the children had complications in the PACU or at the residence.</li>
	<li>With this technique, there is no need to perform venipuncture in children.</li>
	<li>Hospital discharge occurred around 19 minutes after RT.</li>
</ul>
</div>

<p><strong>INTRODUCTION</strong></p>

<p>The number of new cases of childhood cancer is expected in Brazil, for each year of the triennium 2020-2022, there will be 4,310 new cases in males and 4,150 for women [1]. These values correspond to an estimated risk of 137.87 new cases per million for males and 139.04 per million for females [1]. The predominant types of cancer in the age group 0-19 years published by the American Cancer Society in 2019 are leukemia (28%), central nervous system (26%), and lymphomas (8%) [2].</p>

<p>Unlike adult cancer, childhood cancer is predominantly of embryonic nature and usually affects blood system cells and tissues of support. The most common childhood cancers include leukemia, brain and CNS tumors, and lymphomas, with neuroblastomas, Wilms tumors, and sarcomas being less common [3].</p>

<p>Radiotherapy (RT) is a fundamental part of cancer treatment in pediatric patients. Radiation therapy is used to target tumors in specific locations. Depending on the clinical context of disease in each patient, treatment paradigms can vary markedly from single-modality therapy to combinations of surgery, systemic therapy, targeted agents, and/or RT [4]. The use of RT has historically been one of the great successes in the treatment of pediatric cancers [5]. Today, around 80% of children and adolescents affected by the disease can be cured if diagnosed early and treated in specialized centers [1].</p>

<p>RT can be delivered in two ways, externally and internally. The majority of pediatric cancers are treated with external radiation. For the topography precision that these techniques require maintaining the same position and immobility during procedures is imperative [6]. Sedation and/or general anesthesia are commonly utilized to facilitate RT treatment in children. Performing safe and effective anesthesia for pediatric cancer patients undergoing RT presents several challenges Precise positioning and immobilization of the patient during treatment is essential to ensure that high-energy radiation can be delivered to the tumor, whilst minimizing exposure to healthy surrounding tissues [7]. Treatment with RT is usually short-lived, but they must remain immobile and often lie down [7]. In addition, childhood must be continuously monitored by the cardiovascular and respiratory systems, through remote control [7].</p>

<p>Our primary objectives in the present study were to determine the technique of inhalational anesthesia with sevoflurane and without venous access and the incidence of anesthesia-related complications in children aged 2 to 13 years undergoing RT at the National Cancer Institute (INCA). As secondary objectives we also checked the pharmacologic regimens, monitoring techniques, need for venous access or the use of access previously present, preoperative fasting time, duration of the procedure, and release time for residency.</p>

<p><strong>METHODS</strong></p>

<p>This is a descriptive, observational, and prospective study during the period of January 2022 to December 2022. This study was registered in Plataforma Brasil (<strong>CAAE</strong>: 91507318.1.0000.5274) and was approved by the Ethics Committee Scientist in Instituto Nacional de C&acirc;ncer (INCA) with number 2.762.022. The informed consent form was signed by one of the children&#39;s parents. The data were obtained from the clinical records of each patient and were integrated into the electronic sheet, to later carry out the processing of the information and descriptive statistical analysis of the study variable.</p>

<p>Inclusion criteria were pediatric population aged 2 to 13 years of age undergoing general inhalation anesthesia without venous access undergoing RT, with confirmed oncological diagnosis and regardless of histological type or staging. Patients older than 13 years, who refused a legal guardian, used intravenous anesthesia, and had simulation sessions were excluded from the study.</p>

<p>All RTs were performed with the TrilogyTM device. The TrilogyTM lineae accelerator from Varian Medical Systems was used to perform the radiotherapy, which presents the techniques of 3D-CRT (conformational radiotherapy), IMRT (intensity-modulated beam radiotherapy), and IGRT (image-guided radiotherapy). Pre-molded thermoplastic masks were used in simulation sessions to ensure complete immobilization during radiotherapy in patients with central nervous system, neuraxial, and head and neck tumors.</p>

<p>Each day a different anesthesiologist is always accompanied by an anesthesiology resident. Due to the different conducts, a day was selected for the implementation of the inhalation anesthesia protocol with sevoflurane without venipuncture, with the same anesthesiologist, and accompanied by the same resident.</p>

<p>Patients were monitored with a cardioscope, non-invasive blood pressure, pulse oximetry, capnography, and gas analyzer to perform the procedures. The anesthetic technique performed was general inhalation anesthesia with sevoflurane and 100% oxygen (4 l/min) flow under a face mask (without tracheal intubation) in a semi-closed pediatric circuit, valved, with a CO<sub>2</sub> absorber and bacterial filter or Baraka circuit (Mapleson A). The anesthesia device used in this research with children was the Carestation 620 (GE Healthcare) suitable for smaller spaces such as RT. This device (Carestation 620) allows the evaluation of MAC, capnometry, capnography, analysis of gases used, inspired and expired fractions. Its eco-flow software visually represents oxygen flow and anesthetic agent usage. Peripheral venous accesses were not punctured during the sessions and venous accesses previously punctured in other sectors were not used.</p>

<p>We collected demographic data, including age, weight, height, sex, ASA physical status, oncology diagnosis, and local RT procedure. The information collected from the anesthesia record included anesthesia duration (interval between first administration of drugs and completion of RT procedure), anesthetic drugs used (selection of drugs, use of adjuvant drugs, total dose), patient position, fasting time, number of RT sessions, need for venous access, irradiation time, tumor site, awakening and length of stay in the post-anesthetic care unit (PACU).</p>

<p>During the procedure, the following were evaluated: the expired fraction of sevoflurane and the corresponding Minimum Alveolar Concentration (MAC) for induction and maintenance, anesthesia and awakening time, place and time of irradiation, and immediate and late adverse effects (after awakening until discharge hospital). Finally, the time of hospital discharge and complications were evaluated after completion. After completing the procedure, the children were awakened and referred to the PACU, and the time for discharge to residency was recorded.</p>

<p>The anesthesia-related complications were: oxygen desaturation (saturation &lt;90%), apnea (absence of respiratory effort for &gt;15 s), airway obstruction (required interventions), and minor airway complications. Hemodynamic complications were defined as any recorded variations in heart rate.</p>

<p><a name="_Hlk130798251"><strong>Statistical analysis </strong></a></p>

<p>For the analysis of continuous variables, we used the Wilcoxon-Mann-Whitney test. The Wilcoxon-Mann-Whitney test is used to compare two groups to verify whether they belong to the same population. It is used when the samples are independent. For the analysis of qualitative variables, we used the Chi-Square test. The Chi-Square independence test is used to find out if there is an association between the row variable and the column variable in a contingency table constructed from sample data. We used the significance level of 5%.</p>

<p><strong>RESULTS</strong></p>

<p>A total of 693 RTs were performed between January 2022 and December 2022 with the TrilogyTM device. Of this total, 154 RT in children were performed on Tuesday and 539 RT on other days. 129 RT were excluded and 25 children submitted to RT under inhalation anesthesia with sevoflurane without venipuncture were analyzed as a pilot project, according to the flow diagram consort (Figure 1). Five children previously had venous access, and it served as a control for side effects and whether they would need to use it.</p>

<p style="text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/Fig11.png" style="height:397px; width:600px" /></p>

<p style="text-align: center;"><strong>Figure</strong> <strong>1</strong>. Consort flow diagram.</p>

<p>Demographic data for the 25 children are in Table 1, Figure 2. All children were considered Physical Status ASA II. Twenty-four (96%) of the 25 children were between 2 and 8 years old. Sixteen (60%) were 4 and 5-year-old children. Regarding the oncological diagnosis, the following tumors were found: rhabdomyosarcoma with a total of 6 patients, Wilms&#39; tumor with of 4 patients, medulloblastoma with of 4 patients, glioma with of 4 patients, sialoblastoma with of 3 patients, brain stem tumor with of 3 patients, and cerebral tumor not determined with 1 patient. In this way, several sites were irradiated according to the type and location of the tumors. The skull and neuroaxis were irradiated in 12 children, followed by the face in 8 children, the thorax in 2 children, and the flank, pelvis, and lower limb in 3 children.</p>

<p style="text-align: center;"><strong>Table 1.</strong> Patients&rsquo; characteristics regarding age, weight, height, and sex (Mean&plusmn;SD).</p>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td>
			<p style="text-align: center;"><strong>VARIABLE</strong></p>
			</td>
			<td>
			<p style="text-align: center;"><strong>CHILDREN</strong></p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Number</p>
			</td>
			<td>
			<p style="text-align: center;">25</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Age (years)</p>

			<p>(Minimum-Maximum)</p>
			</td>
			<td>
			<p style="text-align: center;">4.80&plusmn;2.14</p>

			<p style="text-align: center;">(2 &ndash; 13)</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Weight (kg)</p>

			<p>(Minimum-Maximum)</p>
			</td>
			<td>
			<p style="text-align: center;">20.93&plusmn;8.14</p>

			<p style="text-align: center;">(12 &ndash; 47)</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Height (cm)</p>

			<p>(Minimum-Maximum)</p>
			</td>
			<td>
			<p style="text-align: center;">111.20&plusmn;15.40</p>

			<p style="text-align: center;">(90 &ndash; 151)</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Gender: F / M</p>
			</td>
			<td>
			<p style="text-align: center;">12 / 13</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;"><img alt="" src="/userfiles/images/Anesthesia/Fig22.png" style="height:286px; width:600px" /></div>

<p style="text-align: center;"><strong>Figure 2.</strong> Anthropometric data.</p>

<p>With regard to medications in use, 16 children were not using any medication, 7 patients were using dexamethasone to control cerebral edema caused by the tumor, 3 children were associated with omeprazole, 1 child was using risperidone to treat autistic spectrum and 1 child was using morphine for pain control.</p>

<p>All children were anesthetized for RT on an outpatient basis, having arrived at the hospital on the morning of the procedure. Thus, the fasting time of the children was 10.12&plusmn;1.61 hours, ranging from 8 to 14 hours. During anesthesia, venous accesses were not punctured, but 5 patients already had a previous implantable venous catheter, which was not used during the RT session.</p>

<p>All children were monitored with a cardioscope, pulse oximetry, and capnograph, but non-invasive blood pressure was never used. The pediatric semi-closed circuit with CO2 absorber and bacterial filter was the most used in 18 children, the Baraka circuit (Mapleson A) in 6 children, and in 1 child the semi-closed adult system was used. For anesthetic induction, sevoflurane was used with an average MAC value of 1.5&plusmn;0.3 (ranging from 09 to 2.5) and an average value for anesthetic maintenance was 0.8&plusmn;0.2 (ranging from 0.5 to 1.3) (Table 2).</p>

<p style="text-align: center;"><strong>Table 2</strong>. Comparing immediate adverse effects (n=10) with the absence of adverse effects (n=15) and possible correlations.</p>

<table align="center" border="1" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td>
			<p style="text-align: center;"><strong>VARIABLES</strong></p>
			</td>
			<td>
			<p style="text-align: center;"><strong>NOT=15</strong></p>
			</td>
			<td>
			<p style="text-align: center;"><strong>YES=10</strong></p>
			</td>
			<td>
			<p style="text-align: center;"><strong>P-VALUE</strong></p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Age (years)</p>
			</td>
			<td>
			<p style="text-align: center;">5.40&plusmn;2.55</p>
			</td>
			<td>
			<p style="text-align: center;">3.90&plusmn;0.73</p>
			</td>
			<td>
			<p style="text-align: center;">0.04435*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Weight (kg)</p>
			</td>
			<td>
			<p style="text-align: center;">22.32&plusmn;9.49</p>
			</td>
			<td>
			<p style="text-align: center;">18.86&plusmn;5.36</p>
			</td>
			<td>
			<p style="text-align: center;">0.5969*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Height (cm)</p>
			</td>
			<td>
			<p style="text-align: center;">115.86&plusmn;17.78</p>
			</td>
			<td>
			<p style="text-align: center;">104.20&plusmn;7.05</p>
			</td>
			<td>
			<p style="text-align: center;">0.05444*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Gender: F / M</p>
			</td>
			<td>
			<p style="text-align: center;">7 / 8</p>
			</td>
			<td>
			<p style="text-align: center;">5 / 5</p>
			</td>
			<td>
			<p style="text-align: center;">1.0000**</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Fasting Time (h)</p>
			</td>
			<td>
			<p style="text-align: center;">10.26&plusmn;1.83</p>
			</td>
			<td>
			<p style="text-align: center;">9.90&plusmn;1.28</p>
			</td>
			<td>
			<p style="text-align: center;">0.8198*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>MAC Sevoflurane Induction</p>
			</td>
			<td>
			<p style="text-align: center;">1.47&plusmn;0.39</p>
			</td>
			<td>
			<p style="text-align: center;">1.75&plusmn;0.31</p>
			</td>
			<td>
			<p style="text-align: center;">0.07727*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>MAC Sevoflurane Maintenance</p>
			</td>
			<td>
			<p style="text-align: center;">0.83&plusmn;0.19</p>
			</td>
			<td>
			<p style="text-align: center;">0.89&plusmn;0.24</p>
			</td>
			<td>
			<p style="text-align: center;">0.8218*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Anesthesia Time (min)</p>
			</td>
			<td>
			<p style="text-align: center;">23.60&plusmn;7.59</p>
			</td>
			<td>
			<p style="text-align: center;">22.0&plusmn;5.77</p>
			</td>
			<td>
			<p style="text-align: center;">0.5771*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Irradiation Time (min)</p>
			</td>
			<td>
			<p style="text-align: center;">12.06&plusmn;6.05</p>
			</td>
			<td>
			<p style="text-align: center;">9.0&plusmn;2.78</p>
			</td>
			<td>
			<p style="text-align: center;">0.2423*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Wake-up Time (min)</p>
			</td>
			<td>
			<p style="text-align: center;">6.06&plusmn;2.46</p>
			</td>
			<td>
			<p style="text-align: center;">6.20&plusmn;2.89</p>
			</td>
			<td>
			<p style="text-align: center;">0.9777*</p>
			</td>
		</tr>
		<tr>
			<td>
			<p>Hospital Discharge (min)</p>
			</td>
			<td>
			<p style="text-align: center;">20.20&plusmn;6.67</p>
			</td>
			<td>
			<p style="text-align: center;">17.30&plusmn;6.56</p>
			</td>
			<td>
			<p style="text-align: center;">0.3152*</p>
			</td>
		</tr>
	</tbody>
</table>

<div style="clear: both; text-align: center;">*Teste de Wilcoxon</div>

<div style="clear: both; text-align: center;">**Teste Qui-quadrado</div>

<p>Mean anesthesia time was 22.96&plusmn;6.84 minutes (ranging from 12 to 38 minutes), mean irradiation time was 10.84&plusmn;5.16 minutes (ranging from 4 to 26 minutes), and mean awakening time was 6.12&plusmn;2.58 minutes ( ranging from 2 to 11 minutes). All children were discharged from the hospital in 10 to 35 minutes, with an average of 19.04&plusmn;6.65 minutes (Table 2).</p>

<p>Ten children had side effects during and upon awakening, and 15 children had no immediate adverse effects. Agitation was observed at the end of the procedure in 5 children, bradycardia in 4 children during the anesthetic with no hemodynamic instability, and 1 child had laryngospasm that was easily recovered with positive pressure ventilation.</p>

<p>Inferential statistical analysis showed that the only study variable that showed a significant difference in the increased risk of immediate adverse effects was the expired fraction of sevoflurane and the corresponding MAC used in anesthetic induction (Table 2). Furthermore, these effects were more frequent when they reached values greater than or equal to 1.5 MAC.</p>

<p>None of the children had complications in the PACU or at the residence, by follow-up via telephone. None of the children in this study with inhalational anesthesia with sevoflurane without venipuncture required orotracheal intubation or hospitalization after RT.</p>

<p><strong>DISCUSSION</strong></p>

<p>Radiotherapy is of fundamental importance for the treatment of pediatric cancer, and the vast majority of children who will undergo RT will require sedation or anesthesia. The first objective of this study showed that inhalational anesthesia with sevoflurane without venoclysis was perfectly feasible and safe, with a low incidence of side effects in outpatients with hospital discharge in an average of around 20 minutes. There was no significant difference between the incidence of men and women, and 96% of children were younger than 8 years.</p>

<p>Ideal anesthetic agents for use in RT should show a rapid onset of action, with sedation, hypnosis, and amnesia, have a short duration of effect, show a safety profile with repeated administration together with a low risk of tachyphylaxis, minimal adverse effects, and good relationship cost-effectiveness. In this way, it facilitates painless administration of anesthetic, to achieve immobilization and with it maintain in a single position to the patient, as well as ensuring a patent airway in a variety of positions according to each case, all this with the purpose that this intervention entails a minimum interference with daily activity [7].</p>

<p>Sevoflurane is an ether inhalation general anesthetic agent with a lower solubility in blood than isoflurane or halothane but not desflurane and fulfills all the requirements of an ideal anesthetic for inhalation use in children. The low solubility and the absence of pungency facilitate rapid mask induction; the low blood solubility also expedites wash-out and therefore recovery from anesthesia. Sevoflurane allowed a smooth and rapid induction with an average of 1.5 MAC, maintenance with 0.8 MAC, an average wake-up time of 6.12 minutes, and hospital discharge with an average of 19.04 minutes, without complications. Other services prefer the use of propofol in 100% of children, but venipuncture is necessary [7,8]. The rate of anesthesia-related complications was low (1.3%) in a study with propofol has become the drug of choice at your institution [7].</p>

<p>At the INCA, with the advent of sevoflurane, the use of inhalational anesthesia without venoclysis has been used for years, but no study has been carried out on this technique. The objective of this study was to demonstrate, in a pilot study with 25 children, the possibility of performing RT without the use of venous access, which was obtained in all children, with a low incidence of complications, and became the technique of choice in our institution. This pilot study confirmed what was done for a long time without the aim of a scientific study, showing that the technique is safe, feasible, easily performed, non-invasive, and low-cost (mono drug).</p>

<p>An estimated 11,060 new cancer cases will be diagnosed among children ages 0 to 14 years in the US in 2019 [2]. The number of new cases of childhood cancer estimated for Brazil, for each year of the triennium 2023 to 2025, is 7,930 cases, which corresponds to an estimated risk of 134.81 per million children and adolescents [9]. It is estimated that approximately 430,000 new cases of cancer occur among children and adolescents (from 0 to 19 years old). The main types of cancer that occur in children are leukemias, CNS tumors, and lymphomas. The embryonic tumors (neuroblastoma, renal tumors, and retinoblastoma) mostly affect children, while in adolescents aged 15 to 19 years, tumors are more frequent epithelial cells, such as thyroid and carcinomas, and melanomas [9]. Treatment for childhood cancer is based mainly on the type and stage (extent) of cancer. The main types of treatment used for childhood cancer are surgery, radiation therapy, and chemotherapy. Radiation exposure to the brain can predispose one to hearing loss, impaired neurocognition, and neuroendocrine dysfunction, among other functional deficits [10]. It was not the object of this study to evaluate the complications of RT.</p>

<p>In a recent review, almost all intravenous drugs such as midazolam, propofol, ketamine, and dexmedetomidine were indicated for sedation-anesthesia for the radiation therapy procedure [11]. In this review, the technique used in this study, sevoflurane without performing venipuncture, essential for intravenous anesthesia, was not suggested. This technique in this pilot study with 25 children proved to be safe and easy to perform. The pediatric semi-closed circuit with CO<sub>2</sub> absorber and bacterial filter was the most used in 18 children, the Baraka circuit (Mapleson A) in 6 children, and only one child was 13 years old when she was anesthetized with an adult circuit. The majority of children who require anesthetic intervention can tolerate the daily therapeutic regimen with only monitored anesthesia care [12]. In the review article, the intravenous route is the preferred method of administering medication to these patients [12].</p>

<p>A total of 9,328 were administered to 340 children retrospective reviews of anesthetic records for patients treated with proton therapy, all patients received TIVA with spontaneous ventilation and oxygen delivery by face mask or nasal cannula. None required daily endotracheal intubation. Two episodes of bradycardia and one episode each of; seizure, laryngospasm, and bronchospasm were identified for a cumulative incidence of 0.05% [13]. In this study, sevoflurane monotherapy without venous access, and oxygen through a mask or nasal cannula, presented a low incidence of easily corrected complications, being a new option for RT, and no need for tracheal intubation. Sevoflurane has negligible airway irritant effects, which facilitates a smooth induction in pediatric patients, and makes sevoflurane especially amenable to rapid induction of anesthesia and rapid awakening.</p>

<p>Administration of sevoflurane in doses ranging from 0.4 to 1.2 MAC is associated with a stable [14]. In this study with sevoflurane monotherapy showed an increased risk of immediate adverse effects, with the expired fraction of sevoflurane and the corresponding MAC used in anesthetic induction. These effects were more frequent when they reached values greater than or equal to 1.5 MAC.</p>

<p>In this study, the average pre-procedure fasting time was high in relation to the current recommendations of 6 hours for solid foods and 1 hour for clear liquids, according to a consensus published in Pediatrics [15]. In this context, prolonged fasting time may increase the risk of dehydration, arterial hypotension, bradycardia and cause discomfort to the patient. This fact may explain the bradycardia without hemodynamic instability in the four patients in the study since they had fasted for more than 8 hours. Despite this, this study did not present statistical significance in the inferential analysis of the data, when relating fasting time with the risk of adverse effects during anesthesia.</p>

<p><strong>CONCLUSION</strong></p>

<p>Radiation therapy has proved to be an important armamentarium for cancer management in children. The procedure also requires a motionless child to deliver the radiation at the intended site and thus avoid unnecessary radiation exposure. The delivery of safe and effective anesthesia for pediatric oncology patients undergoing RT presents several challenges. Providing anesthesia for children undergoing radiation treatment is both challenging and rewarding. The vast majority of cited and researched articles prefer to use intravenous anesthesia with different types of drugs. Sevoflurane as monotherapy without venous access turned out to be a safe technique, easy to perform with no severe complications, with rapid awakening and hospital discharge and is the preferred method of choice in these children in our institution.</p>

<p><strong>FINANCIAL SUPPORT</strong></p>

<p>None.</p>

<p><strong>CONFLICT OF INTEREST</strong></p>

<p>None.</p>

<p><strong>CONTRIBUTION</strong></p>

<p>No.</p>

<p><strong>IRB</strong></p>

<p>No.</p>

<p><strong>DISCLOSURES</strong></p>

<p><strong>Name</strong>: Luiz Eduardo Imbelloni, MD, PhD.</p>

<p><strong>Contribution</strong>: This author helped with study conception and design, this author helped perform background research, statistical analysis, generation of tables and figures, analysis and interpretation of data, selected all the references used for the preparation of the study, wrote the entire manuscript, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: D&eacute;bora Baroni, MD.</p>

<p><strong>Contribution</strong>: Anesthesiologist resident scheduled to perform RT under inhalational anesthesia, and monitor the children&#39;s evolution. Revised the manuscript critically for intellectual content, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: Patr&iacute;cia L. Proc&oacute;pio Lara, MD.</p>

<p><strong>Contribution</strong>: Anesthesiologist resident scheduled to perform RT under inhalational anesthesia, and monitor the children&#39;s evolution. Revised the manuscript critically for intellectual content, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: Sylvio Valen&ccedil;a de Lemos Neto</p>

<p><strong>Contribution</strong>: This author helped with study conception and design, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: Ana Cristina Pinho</p>

<p><strong>Contribution</strong>: This author helped with study conception and design, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: Anna L&uacute;cia Cala&ccedil;a Rivoli</p>

<p><strong>Contribution</strong>: This author helped with study conception and design, and gave final approval of the manuscript.</p>

<p><strong>Name</strong>: Geraldo Borges de Morais Filho, MSc.</p>

<p><strong>Contribution</strong>: This author performed statistical analysis, generation of figures, analysis, and interpretation of data, revised the manuscript critically for intellectual content, and gave final approval of the manuscript.</p>

<p><strong>This manuscript was handled by</strong>: Luiz Eduardo Imbelloni, MD, Ph.D.</p>

<p><strong>REFERENCES</strong></p>

<ol>
	<li>Schilithz AOC, Lima FCS, Oliveira JFP, Santos MO, Rebelo MS. Instituto Nacional de C&acirc;ncer Jos&eacute; Alencar Gomes da Silva. Estimativa 2020: incid&ecirc;ncia de c&acirc;ncer no Brasil/Instituto Nacional de C&acirc;ncer Jos&eacute; Alencar Gomes da Silva.&ndash;Rio de Janeiro: INCA, 2019. ISBN 978-85-7318-388-7.</li>
	<li>American Cancer Society. Cancer Facts &amp; Figures 2019. Atlanta: American Cancer Society; 2019. Global Headquarters: American Cancer Society Inc. 250 Williams Street, NW, Atlanta.</li>
	<li>Ries L, Melbert D, Krapcho M, et al. (2012). SEER Cancer Statistics Review, 1975&ndash;2004. Bethesda, MD: National Cancer Institute.</li>
	<li>DeNunzio NJ, Yock TI. (2020). Review modern radiotherapy for pediatric brain tumors. Cancers. 12(6):1533. DOI: 10.3390/cancers12061533.</li>
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	<li>McFadyen JG, Pelly N, Orr RJ. (2011). Sedation and anesthesia for the pediatric patient undergoing radiation therapy. Curr Opin Anaesthesiol. 24(4):433-438.&nbsp;DOI:10.1097/aco.0b013e328347f931.</li>
	<li>Anghelescu DL, Burgoyne LL, Liu W, et al. (2008). Safe anesthesia for radiotherapy in pediatric oncology: St. Jude Children`s research hospital experience, 2004-2006. Int J Radiation Oncology Biol Phys. 71(2):491-497. DOI:10.1016/j.ijrobp.2007.09.044.</li>
	<li>Alvarado-Valverde AM, Ram&iacute;rez-Montero A, Esquivel-Gonz&aacute;lez J, Rodr&iacute;guez-Rodr&iacute;guez C. (2021). Use of sedation and anesthesia in the pediatrics patients undergoing radiotherapy. Acta M&eacute;d Costarric. 63(1):14-20.</li>
	<li>Instituto Nacional de C&acirc;ncer (Brasil). (2022). Estimativa 2023: incid&ecirc;ncia de c&acirc;ncer no Brasil. Instituto Nacional de C&acirc;ncer. Rio de Janeiro: INCA. p. 60-61.</li>
	<li>DeNunzio NJ, Yock TI. (2020). Modern radiotherapy for pediatric brain tumors. Review. Cancers. 12(6):1-16. DOI: 10.3390/cancers12061533.</li>
	<li>Gupta M, Garg R. (2017). Radiation therapy for children: periprocedural anaesthetic concerns. Review Article. J Anesth Crit Care Open Access. 8(2):1-3. DOI: 10.15406/jaccoa.2017.08.00297.</li>
	<li>Harris EA. (2010). Sedation and anesthesia options for pediatric patients in the radiation oncology suite. Int J Pediatr. 2010:870921. DOI:10.1155/2010/870921.</li>
	<li>Owusu-Agyemang P, Grosshans D, Arunkumar R, et al. (2014). Non-invasive anesthesia for children undergoing proton radiation therapy. Radiother Oncol. 111(1):30-34. DOI: 10.1016/j.radonc.2014.01.016.</li>
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</ol>

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