Inflammation and cardiovascular disease are associated with elevated serum levels of C-Reactive Protein (CRP) and homocysteine. The presence of both molecules in saliva provides an opportunity for development of non-invasive assessments of disease risk. However, salivary CRP and homocysteine reference ranges and their correlation with serum levels are unknown. This study investigated if CRP and homocysteine could be routinely detected in the saliva of healthy adults and the relationship between salivary and blood levels. CRP and homocysteine concentrations were determined using ELISA and enzymatic assays respectively. Homocysteine was detected in only two saliva samples (n = 55). CRP was measurable in all saliva samples (range: 0.05 to 64.3 μg/L; median = 1.2 μg/L) and plasma samples (range: 0.14 to 31.1 mg/L; median = 2.0 mg/L). Regression analysis demonstrated no relationship between CRP concentration in saliva and plasma (R2 = 0.001). Generalized linear models including variables such as saliva flow rate and time since eating or drinking also did not pass lack of fit testing. Therefore, a relationship between CRP concentration in saliva and blood could not be established in this group of subjects. More sensitive detection methods are needed to determine if a correlation between salivary and serum homocysteine levels exists.

Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as “ COVID-19 long-haulers ,” often present with non-specific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There is currently no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the U.S. over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to 7 weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, we define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.

Superior vena cava (SVC) syndrome is typically associated with malignant tumors obstructing the SVC, but as many as 40% of cases have other etiologies. SVC obstruction was previously described during veno-venous extracorporeal membrane oxygenation therapy (VV ECMO) in children. In this report, we describe a woman with adult respiratory distress syndrome resulting from infection with coronavirus-19 who developed SVC syndrome during VV ECMO. A dual-lumen ECMO cannula was inserted in the right internal jugular vein, but insufficient ECMO circuit flow, upper body edema, and signs of hypovolemic shock were observed. This clinical picture resolved when the right internal jugular vein was decannulated in favor of bilateral femoral venous cannulae. Our report demonstrates that timely recognition of clinical signs and symptoms led to the appropriate diagnosis of an uncommon ECMO complication.

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