Blackpool Victoria Hospital, known locally as The Vic, is the main hospital for Blackpool and the Fylde Coast in Lancashire, England. It is managed by the Blackpool Teaching Hospitals NHS Foundation Trust.
BACKGROUND:Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is one of the important procedure-related complications of ERCP. Periprocedural intravenous hydration with lactated Ringer's solution has been considered a simple and feasible measure for reducing this complication. The present trial was designed to assess whether aggressive hydration with lactated Ringer's solution was more effective than standard hydration in preventing post-ERCP pancreatitis (PEP). METHODS:This randomized controlled trial was performed at two tertiary care hospitals. A total of 126 patients undergoing first-time ERCP were included and randomly distributed into two equal treatment groups. Patients in group A were managed with standard hydration, whereas patients in group B received aggressive hydration using lactated Ringer's solution. The main outcome measure was the development of PEP. Other recorded outcomes were post-ERCP hyperamylasemia, isolated hyperamylasemia, serial pain scores on the visual analog scale, serum amylase levels, duration of hospital stay, and fluid-related adverse effects. RESULTS:All 126 randomized patients completed the 24-hour assessment. PEP developed in 14 patients in the standard hydration arm and four patients in the aggressive hydration arm (22.2% versus 6.3%; p = 0.020; RR = 0.29, 95% CI = 0.10-0.82). Total post-ERCP hyperamylasemia was less frequent after aggressive hydration than standard hydration (14.3% versus 41.3%; p = 0.001). Isolated hyperamylasemia was recorded in 7.9% and 19.0% of patients, respectively (p = 0.116). Pain scores remained lower with aggressive hydration at 4, 12, and 24 hours (all p < 0.001). Hospital stay was also reduced (1.8 versus 3.0 days; p < 0.001). CONCLUSIONS:Aggressive hydration with lactated Ringer's solution significantly reduced PEP, post-procedure hyperamylasemia, pain scores, and hospital stay compared with standard hydration. The regimen was well tolerated in selected patients without fluid-overload risk.
Abnormal central venous anatomy can obstruct cardiac-device implantation. We report a 54-year-old patient found to be in complete heart-block after identification of profound bradycardia, requiring cardiac-pacing. Echocardiography revealed systolic dysfunction, prompting a plan for cardiac resynchronization therapy. Conventional lead placement was impossible due to failed guide-wire advancement bilaterally. Peri-procedural venography demonstrated attenuation of both brachiocephalic veins and contrast-enhanced computed tomography confirmed complete central venous occlusion (CVO). Further history identified previous chemotherapy delivered via central venous catheters, as the likely aetiology for the CVO and systolic dysfunction. Alternative pacing options were considered. Ultimately the leadless Micra-AV-pacemaker was successfully implanted via the femoral vein with good clinical recovery. This unique case highlights CVO as an obstacle to cardiac-device implantation, with specific patients at increased risk. Pre-procedural imaging in those at-risk may reduce procedure failure and facilitate appropriate device strategy choice. Leadless pacing provides a safe, effective alternative in cases of CVO.
Despite the increasing availability of IV analgesics, perioperative pain management remains a challenge, especially in pediatric care where most IV NSAIDs do not have labelled indications. NSAIDs are consistently identified as essential for multimodal analgesia protocols. This document summarizes key discussions of a 2023 Medical Advisory Board Meeting (Frankfurt, Germany) on Ready-to-use (RTU) IV Ibuprofen, complemented by follow-up clinician questionnaires describing institutional clinical protocols, perceived benefits and safety considerations. Ready-to-use IV ibuprofen has become available in Europe in the last few years, prior to its worldwide launching. This paper aims to provide valuable insights and serve as a reference point for the introduction of this new formulation by colleagues in other countries. Ibuprofen inhibits COX-1 and COX-2 enzymes with a favorable COX-1/COX-2 ratio, reducing side effects. Its pharmacokinetics are consistent across age groups, and it is considered safe for pediatric and elderly populations. Experts reported broad adoption of RTU IV Ibuprofen across multiple surgical settings, with consistent analgesic efficacy and evident opioid-sparing effects. Protocols referred by the authors included mainly preemptive analgesia and multimodal strategies tailored to patient needs. Reported advantages for IV Ibuprofen included rapid onset of action, accurate dosing, faster recovery, and workflow benefits from a premixed preparation, making it suitable for hospitalized patients. Contraindications include allergies, active bleeding, and severe renal failure. Board members reported no increased bleeding risk in their experience with IV Ibuprofen.
Background and Clinical Significance: Ischaemia with non-obstructive coronary arteries (INOCA) has attained more recognition in recent decades. These patients may present with typical cardiac sounding chest pain but have no evidence of obstructed coronary arteries on coronary angiography. This presents a challenge to clinicians in terms of diagnosis and management. Coronary microvascular dysfunction (CMD), or coronary spasm (whether epicardial or microvascular) may be the cause of their presentation, and they usually require further invasive investigations of their coronary microvascular circulation to determine the cause. Case Presentation: This case involves a male patient in his 60s presenting with recurrent nocturnal chest pain, clinical and ECG evidence of ischaemia, and diagnostic findings from invasive coronary angiography and a microvascular study. These findings confirmed an absence of obstructive coronary artery disease (CAD) but demonstrated significant microvascular dysfunction, consistent with a diagnosis of microvascular angina according to the COVADIS criteria, as well as epicardial coronary artery spasm leading to complete vessel closure. This case highlights the clinical and diagnostic complexities of microvascular angina and coronary artery spasm. It also emphasises the importance of advanced diagnostic testing in confirming this challenging diagnosis. This case was interesting due to the patient having a final diagnosis of microvascular angina and coronary artery spasm at the same time. This case also demonstrates how 300 mcg of intracoronary nitrate was given to dilate a vessel in coronary spasm with positive effect. This finding was supportive of the final diagnosis given the clinical context of this patient. Conclusions: This case report demonstrates the diagnostic steps, from symptom assessment through to angiography and microvascular testing and would add to the existing knowledge of INOCA and aid in the understanding and management of these patients especially in centres where acetylcholine testing to confirm inducible epicardial coronary spasm is not available, like it was not in our centre (Blackpool Victoria Hospital).
