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Signa Vitae

Journal of Intensive Care and Emergency Medicine

A prognostic value of early urinary biomarkers NGAL and IL-18 in critically ill children: a 10-year literature review

Abstract

Introduction. Acute kidney injury (AKI) is a life-threatening syndrome caused by a sudden and rapidly progressing impairment of renal function. It is a common and complicated clinical entity among hospitalized children, occurring in 2%-4.5% of children treated in a pediatric intensive care unit. Mortality among such patients remains high (from 8% to 89%) despite improving patient care and technical possibilities. The stage of renal damage is a reversible process, and its timely detection would prevent the progression of renal damage and thus reduce pediatric mortality rates. Therefore, modern medicine necessitates the identification of novel AKI biomarkers that would correlate with renal cell damage and could be detected earlier than a rise in serum creatinine (sCr). Neutrophil gelatinase-associated lipocalin (NGAL) and interleukin 18 (IL-18) are one of such early markers of AKI.

Aim. To carry out a literature review of studies on changes in NGAL and IL-18 levels in the urine of critically ill patients and to determine a prognostic value of these biomarkers in the detection of renal injury and impact on disease outcomes.

Material and methods. This literature review includes the publications of biomedical studies assessing early biomarkers of AKI in urine (uNGAL or uIL-18) of critically ill children, published in English during the 10-year period. Search for publication was performed in the PubMed database.

Results. Analysis included 10 studies that investigated early biomarkers of AKI (NGAL or IL-18) in urine of critically ill children and compared them with sCr. Among the biomedical studies analyzed in our literature review, 9 measured the NGAL level in urine or both in urine and serum, while 2measured IL-18 in urine. It was determined that uNGAL and uIL-18 were good early diagnostic biomarkers of AKI, which increased 48 h earlier than Cr in serum (P<0.005). The meta-analysis carried out by Haase et al. showed that uNGAL predicted the development of AKI better in critically ill children than in adults (OR, 25.4; ROC, 0.930 vs. OR, 10.6; ROC, 0.782). Three studies reported that the uNGAL level in study populations with AKI directly depended on disease severity and AKI degree (P<0.005). Four studies found that uNGAL and one study that uIL-18 are good predictive factors of mortality (P<0.005).

Conclusions. uNGAL and uIL-18 are early predictive biomarkers of AKI in critically ill children. uNGAL and uIL-18 level correlated well with disease severity and are independent predictive biomarkers of mortality.

Key words: acute kidney injury, critically ill children, biomarkers, uNGAL, uIL-18.

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Validation of tracheal intubation of wire-reinforced endotracheal tube with ultrasonography

Abstract

Objective. The use of ultrasonography (US) is a new method for verifying the location of the endotracheal tube.

Design. Our study was designed as a paired-data and investigator-blind clinical study for evaluating the effectiveness of US for verification of wire-reinforced endotracheal tube (WR-ETT) placement compared with capnography.

Setting. This study was conducted on 56 patients scheduled for elective surgery under general anesthesia.

Patients. Fifty patients completed the study as 6 were excluded for various reasons.

Intervention. Two different investigators performed the ultrasonography and intubation independently from one another. While investigator 1 attempted to verify the location of the WR-ETT with a portable ultrasonography with sagittal trans-tracheal view, investigator 2 intubated the patient and verified the location of the ETT using capnography.

Measurements. Time for verifying the location of the ETT using both US and capnography was recorded.

Main Results. When the ultrasonography method was compared with capnography for verification of the WR-ETT placement, the results showed 95.75% sensitivity and 100% specificity. The average verification times for endotracheal intubation were 12.78 ± 7.46 s. and 24.44 ± 1.45 s. with US and capnography, respectively (p=0.003).

Conclusion. Our results suggest that ultrasound identification of a WR-ETT within the trachea is a rapid and accurate method for confirmation of tracheal placement. Larger studies are needed before widespread use of this technique.

Key words: endotracheal tube, intubation, ultrasonography, capnography

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Ketamine use for endotracheal intubation in severe sepsis and septic shock

Abstract

Objective. We conducted this study to evaluate the clinical outcomes of patients with severe sepsis and septic shock who were treated with ketamine for endotracheal intubation.

Methods. A single-center, retrospective study was carried out to compare the outcomes of patients with severe sepsis and septic shock who received a ketamine or non-ketamine agent for rapid sequence intubation (RSI). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED), met the criteria for severe sepsis or septic shock, and underwent endotracheal intubation between August 2008 and March 2014. The primary outcome was 28-day mortality. We performed a multivariable logistic regression analysis to assess the association between ketamine use for intubation and 28-day mortality.

Results. In all, 170 patients were intubated during the study period. Of the eligible patients, 95 received ketamine and 75 received a non-ketamine agent. The 28-day mortality of the ketamine group was not significantly different from that of the non-ketamine group (38% vs. 40%, respectively, P=0.78). The unadjusted odds ratio (OR) of ketamine use for 28-day mortality was 0.92 (95% CI: 0.49–1.70, P=0.78). The association remained insignificant after adjusting for age, gender, malignancy, initial lactate level on ED admission, time to first antibiotic administration, Acute Physiology and Chronic Health Evaluation II score on admission day, and propensity score regarding ketamine use (adjusted OR: 1.09; 95% confidence interval [CI]: 0.49–2.40; P=0.84). Initial serum lactate on ED admission was the only significant predictive factor of 28-day mortality (adjusted OR: 1.23; 95% CI: 1.10–1.38; P<0.01).

Conclusions. For patients with severe sepsis and septic shock who were intubated using RSI, we found no significant difference in 28-day mortality between those who received ketamine as a sedative agent and those who received alternative sedatives.

Key words: sepsis, ketamine, intubation, mortality

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Why should we switch chest compression providers every 2 minutes during cardiopulmonary resuscitation?

Abstract

Objective. This study was conducted to determine whether trained male rescuers could maintain adequate chest compression depth (CCD) for longer than the current recommended guidelines of 2 minutes.

Methods. Forty male medical doctors administered a 5-minute single rescuer cardiopulmonary resuscitation (CPR) to a manikin on the floor with conventional CPR or randomly administered continuous chest compressions (CCC). The ratio of compression to ventilation was set to 30:2 with mouth-to-mouth technique during conventional CPR. Chest compression data were recorded with an accelerometer device and divided into 1-minute segments for analysis.

Results. Although average CCD maintained the recommended depths throughout 5 minutes in conventional CPR, it decreased significantly with CCC (1 minute: 55.4 ± 4.5 mm; 2 minutes: 54.2 ± 5.4 mm; 3 minutes: 52.6 ± 5.6 mm; 4 minutes: 51.6 ± 5.5 mm; 5 minutes: 49.9 ± 5.8 mm, p < 0.001). The average chest compression numbers (ACCN) per minute were maintained over 80/min and have not been changed significantly within 5 minutes in the CCC. However, it didn’t reach to the 80/min and decreased significantly after 3minutes compared to the baseline ACCN during first 1-minute segment in the conventional CPR.

Conclusions. Despite the chest compression providers being limited to trained male medical doctors, the average CCD decreased significantly within 5minutes with CCC. Although maintaining adequate CCD, ACCN in each minute decreased significantly after 3minutes in the conventional CPR. Therefore, we should rotate chest compression providers every 2minutes regardless of the rescuer’s qualifications and CPR methods.

Key words: cardiopulmonary resuscitation, mouth-to-mouth resuscitation, cardiac arrest, healthcare provider

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Total plasma sulfide in mild to moderate diastolic heart dysfunction

Abstract

Background. The early pathophysiological mechanisms of diastolic dysfunction are not understood well. Hydrogen sulfide is an important endogenous gaseous transmitter that can influence heart remodeling. The aim was to determine total plasma sulfide (TPS) levels, as a surrogate marker of hydrogen sulfide, in patients with mild diastolic dysfunction.

Methods. Total plasma sulfide and N-terminal pro brain-type natriuretic peptide (NT-proBNP) levels were determined in ambulatory patients with arterial hypertension or diabetes mellitus and echocardiographically mild to moderate diastolic dysfunction.

Results. Twenty-four patients were included: nine with normal diastolic function (Grade 0), eight with an impaired relaxation pattern (Grade 1), and seven with a pseudo-normalized pattern (Grade 2). TPS levels were highest in patients with normal diastolic function (Grade 0), and lowest in patients with Grade 2 diastolic dysfunction, with this difference between Grade 0 and Grade 2 showing statistical significance (p = 0.017). NT-proBNP levels showed the reverse behavior, with this difference again showing statistical significance (p = 0.042).

Conclusions. Total plasma sulfide levels decrease with worsening of diastolic function from normal to moderate diastolic dysfunction.

Key words: total plasma sulfide, hydrogen sulfide, arterial hypertension, diastolic dysfunction, echocardiography

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