Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

Endothelial dysfunction may contribute to pathogenesis of Takotsubo cardiomyopathy, but mechanism underlying endothelial dysfunction in the setting of catecholamine excess has not been clarified. The study reports that D1/D5 dopamine receptor signaling and small conductance calcium-activated potassium channels contribute to high concentration catecholamine induced endothelial cell dysfunction. For mimicking catecholamine excess, 100 μM epinephrine (Epi) was used to treat human cardiac microvascular endothelial cells. Patch clamp, FACS, ELISA, PCR, western blot and immunostaining analyses were performed in the study. Epi enhanced small conductance calcium-activated potassium channel current (ISK1-3) without influencing the channel expression and the effect was attenuated by D1/D5 receptor blocker. D1/D5 agonists mimicked the Epi effect, suggesting involvement of D1/D5 receptors in Epi effects. The enhancement of ISK1-3 caused by D1/D5 activation involved roles of PKA, ROS and NADPH oxidases. Activation of D1/D5 and SK1-3 channels caused a hyperpolarization, reduced NO production and increased ROS production. The NO reduction was membrane potential independent, while ROS production was increased by the hyperpolarization. ROS (H2O2) suppressed NO production. The study demonstrates that high concentration catecholamine can activate D1/D5 and SK1-3 channels through NADPH-ROS and PKA signaling and reduce NO production, which may facilitate vasoconstriction in the setting of catecholamine excess.

BACKGROUND: High levels of catecholamines are cardiotoxic and associated with stress-induced cardiomyopathies. Using a septic shock model that reproduces the reversible cardiomyopathy seen over 10 days associated with human septic shock, we investigated the effects of catecholamines on microcirculatory perfusion and cardiac dysfunction.
RESULTS: Purpose-bred beagles received intrabronchial Staphylococcus aureus (n=30) or saline (n=6). The septic animals were than randomized to epinephrine (1 μg/kg per minute, n=15) or saline (n=15) infusions from 4 to 44 hours. Serial cardiac magnetic resonance imaging, catecholamine levels, and troponins were collected over 92 hours. Serial adenosine-stress perfusion cardiac magnetic resonance imaging was performed on septic animals randomized to receive saline (n=8 out of 15) or epinephrine (n=8 out of 15). High-dose sedation was given to suppress endogenous catecholamine release. Despite catecholamine levels largely remaining within the normal range throughout, by 48 hours, septic animals receiving saline versus nonseptic animals still developed significant worsening of left ventricular ejection fraction, circumferential strain, and ventricular-aortic coupling. In septic animals that received epinephrine versus saline infusions, plasma epinephrine levels increased 800-fold, but epinephrine produced no significant further worsening of left ventricular ejection fraction, circumferential strain, or ventricular-aortic coupling. Septic animals receiving saline had a significant increase in microcirculatory reserve without troponin elevations. Septic animals receiving epinephrine had decreased edema, blunted microcirculatory perfusion, and elevated troponin levels that persisted for hours after the epinephrine infusion stopped.
CONCLUSIONS: Cardiac dysfunction during sepsis is not primarily due to elevated endogenous or exogenous catecholamines nor due to decreased microvascular perfusion-induced ischemia. However, epinephrine itself has potentially harmful long-lasting ischemic effects during sepsis including impaired cardiac microvascular perfusion that persists after stopping the infusion.

OBJECTIVE: Our institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques.
METHODS: We retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders.
RESULTS: Among 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49-0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44-0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85-0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups.
CONCLUSIONS: Patients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

BACKGROUND: At present, there is still insufficient understanding of the progression from persistent allergic reactions to severe reactions. Adrenaline remains the preferred medication for severe allergic reactions, and intramuscular injection of adrenaline can also be considered for patients with grade I reactions that are difficult to alleviate gastrointestinal symptoms. It is worth further discussing whether it is possible to break the conventional intramuscular injection recommended by the guidelines when the effect of intramuscular injection is not ideal for persistent grade I severe allergic reactions.
METHODS: A young male, 20 years of age, was admitted to emergency department because of repeated rash for 3 days and abdominal pain for 6 hours after taking traditional Chinese medicine. After hormone therapy, the rash continued to recur and secondary gastrointestinal symptoms occurred on the 3th day. Adrenaline intramuscular injection was given to temporarily relieve the rash and abdominal pain, but symptoms still persisted.
METHODS: The patient was diagnosed with persistent severe allergic reaction (grade I).
METHODS: Continuous intravenous infusion of low-dose adrenaline under electrocardiographic monitoring, real-time monitoring of heart rate and blood pressure, and routine treatment with methylprednisolone, diphenhydramine, calcium gluconate, and cetirizine. During this period, adrenaline intramuscular injection is temporarily added when abdominal pain symptoms are obvious. The entire treatment process used a total of 6.8 mg of adrenaline.
RESULTS: During the entire period of adrenaline intervention, the patient did not experience any new discomfort, and there were no abnormal fluctuations in heart rate, rhythm, or blood pressure. The symptoms of rash and abdominal pain gradually improved.
CONCLUSIONS: For patients with persistent grade I severe allergic reactions, intravenous administration of low-dose adrenaline under close vital sign monitoring is safe, feasible, and highly effective in preventing biphasic, persistent, or worsening allergic reactions.

Fascia iliaca compartment block (FICB) reduces opioid consumption and pain scores after total hip arthroplasty (THA), and has recently been widely applied. We investigated whether FICB could also reduce postoperative bleeding. One hundred and fifteen consecutive patients who underwent elective THA under general anesthesia over 5 months were retrospectively analyzed. They were divided into 2 groups: the FICB group received an epinephrine-mixed FICB procedure and the control group did not receive any block. Using the hematocrit measured at 4 different time points (preoperative and 1, 24, and 48 hours after surgery), the estimated blood loss (EBL) was calculated for 3 different time periods (0-1, 1-24, 24-48 hours after surgery). EBL at 1 to 24 hours (226 vs 398 mL, P = .008) was significantly lower in the FICB group than in the control group. Additionally, the number of packed red cell (PRC) units transfused per patient over 48 hours was 0.38 units in the FICB group, which was significantly lower than the 0.70 units used in the control group (P = .040). Epinephrine-mixed FICB in THA has the potential to reduce postoperative bleeding in the first 24 hours after surgery as well as reduce PRC transfusion requirements.

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BACKGROUND: Stress hormones like catecholamine and cortisol are thought to reflect the magnitude of physical stress in adults and were studied in relationship to the cause of death and agony time. Intrauterine distress, intrapartum events, and modes of delivery can affect the fetal endocrine stress response, as reflected by biochemical analyses. The aim of the present study was to evaluate the role of catecholamines and cortisol as markers of ante-mortem fetal distress. The role of cortisol as a marker of circadian timing of delivery was also assessed.
METHODS: A 2-year prospective cohort-comparison inclusion of stillbirths and newborns took place with collection of antemortem data, labor parameters, neonatal outcome, post-mortem data and blood samples. Stillbirths were classified as acute or chronic on the basis of a multidisciplinary evaluation. Heart blood of stillbirths and cord blood of newborns were analyzed by high pressure liquid chromatography (HPLC) for adrenaline and noradrenaline and by immunoassay for cortisol determination.
RESULTS: Fifteen stillbirths and 46 newborns, as a comparison group, delivered by spontaneous vaginal birth, elective, and emergency cesarean sections were included. Stillbirths\' main cause of death was cord thrombosis. Levels of adrenaline and noradrenaline (median: 14,188 pg/ml and 230.5 pg/ml, respectively) were significantly higher (p < 0.001) in stillbirths than in newborns and were also higher in acute compared to chronic distress. Cortisol levels were significantly higher (p < 0.05) in spontaneous vaginal delivery (median: 18.2 μg/dl) compared to elective cesarean sections (median: 3.8 μg/dl). No difference in cortisol concentrations was detected between newborns delivered at morning and at afternoon/evening.
CONCLUSIONS: Our results suggest that the biochemical measurement of adrenaline and noradrenaline levels might reflect a marked physical stress response during the process of death in stillbirths. On the contrary, the elevation of cortisol levels could mirror the elevation in maternal cortisol level during vaginal delivery. For the post-mortem evaluation of stillbirths, the analysis of CA levels could provide additional data on the duration of distress, useful to integrate the forensic diagnosis.

UNASSIGNED: The combination of local anesthetic drugs with epinephrine has conventionally been contraindicated in acral regions due to concerns of potential necrosis caused by compromised blood flow. However, this belief has been challenged since 2001, when studies demonstrated the safety and effectiveness of the combination. This review aims to analyze reported cases of acral area necrosis following the use of local anesthesia with epinephrine since 2001. A thorough search was conducted on PubMed and Google Scholar using specific keywords to identify articles reporting acral area necrosis caused using local anesthesia and epinephrine. Our search yielded eight publications describing a total of 13 cases of ischemic events in acral areas. These cases involved finger necrosis (five cases), scrotal skin necrosis (two cases), and eyelid necrosis (six cases), following the injection of a combination of epinephrine and lignocaine. The majority of affected patients were female who underwent surgical intervention and reconstruction. The use of epinephrine in local anesthesia offers significant advantages and is generally safe for acral areas. However, the risk of necrosis cannot be entirely eliminated, particularly in patients with compromised vascular function. Adhering to proper guidelines and selecting suitable patients can help mitigate the risk. Phentolamine serves as a potential rescue agent if vascular compromise occurs. Precautionary measures must be taken when using this combination in high-risk patients.

Drugs are used during cardiopulmonary resuscitation (CPR) in association with chest compressions and ventilation. The main purpose of drugs during resuscitation is either to improve coronary perfusion pressure and myocardial perfusion in order to achieve return of spontaneous circulation (ROSC). The aim of this up-to-date review is to provide an overview of the main drugs used during cardiac arrest (CA), highlighting their historical context, pharmacology, and the data to support them. Epinephrine remains the only recommended vasopressor. Regardless of the controversy about optimal dosage and interval between doses in recent papers, epinephrine should be administered as early as possible to be the most effective in non-shockable rhythms. Despite inconsistent survival outcomes, amiodarone and lidocaine are the only two recommended antiarrhythmics to treat shockable rhythms after defibrillation. Beta-blockers have also been recently evaluated as antiarrhythmic drugs and show promising results but further evaluation is needed. Calcium, sodium bicarbonate, and magnesium are still widely used during resuscitation but have shown no benefit. Available data may even suggest a harmful effect and they are no longer recommended during routine CPR. In experimental studies, sodium nitroprusside showed an increase in survival and favorable neurological outcome when combined with enhanced CPR, but as of today, no clinical data is available. Finally, we review drug administration in pediatric CA. Epinephrine is recommended in pediatric CA and, although they have not shown any improvement in survival or neurological outcome, antiarrhythmic drugs have a 2b recommendation in the current guidelines for shockable rhythms.