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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Do Inhalational Anesthetic Agents Still Hold Their Place in Modern Anesthesia Practice?


Inhalational anesthetic agents are chemical substances that are administered into the body via lungs and distributed to organs and tissues by blood circulation. The main site of their action is the brain, but they also affect other parts of central nervous system. Volatile and intravenous anesthetics alike have nearly reached the characteristics of an ideal anesthetic, but at a first glance, the increase in use of intravenous anesthetics could likely push out their volatile counterparts. Looking at the situation more thoroughly, positive side effects of volatile anesthetics that are not found in their intravenous counterparts, still give them a place in modern anesthesia practice. It is also possible to combine both techniques to reduce negative adverse effects, while making use of the positive ones.

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Can echocardiographic assessment of interatrial septum shape and motion improve the accuracy of the BLUE protocol?


Acute respiratory failure is one of the most challenging critical conditions due to a wide variety of differential diagnosis. Bedside lung ultrasound in emergency (BLUE) protocol allows accurate differentiation between the most common underlying causes of acute respiratory failure in up to 90% of the cases. The assessment of left atrial pressure affecting left ventricular filling is essential in critically ill patients guiding volume substitution, optimization of left ventricular function and prevention of pulmonary congestion, thus ensuing haemodynamic stability. A simple, non-invasive method of left atrial pressure evaluation is the echocardiographic assessment of interatrial septum shape and motion, which is affected by interatrial pressure gradient. Aiming to improve the accuracy of the BLUE protocol, we propose the simple, non-invasive echocardiographic assessment of interatrial septum shape and motion as an upgrade, providing additional information of the loading of left and right atrium thus distinguishing the most common causes of acute respiratory failure.

Key words: lung ultrasound, BLUE protocol, interatrial septum, echocardiography

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Prophylactic use of the probiotic strain Lactobacillus casei rhamnosus as part of a triple anti-infective regimen in very preterm infants during neonatal intensive care


Background. Probiotics are increasingly used in neonatal intensive care and prove to reduce rates of necrotizing enterocolitis (NEC), sepsis and all-cause mortality by meta-analyses.

Objective. Aim of the study was to analyze the prophylactic use of the probiotic Lactobacillus casei rhamnosus (LCR) as part of a triple anti-infective treatment regimen in very preterm neonates in respect to complications and possible side effects.

Setting. This was a study on 1169 very preterm infants of 32 weeks of gestational age and less born between 2005 and 2015 who were admitted within the first 24 hours of life to the neonatal intensive care unit (NICU) and hospitalized for at least 7 days.

Design. Retrospective observational STROBE compliant single-center cohort study

Intervention. All infants received a standardized prophylactic anti-infective treatment regimen with enteral probiotics (LCR), antifungal agents, and oral gentamycin over the study time starting at the first day of life.

Outcome measures. Perinatal and neonatal data were collected for descriptive analysis. Complications possibly avoided by the anti-infective regimen included NEC, late-onset sepsis (LOS), late-onset multiple organ dysfunction syndrome (MODS), and ventilator associated pneumonia (VAP).

Main results. Eleven of 1169 infants 11 (0.9%) had diagnosis of NEC ≥ IIa, 141 (12.1%) exhibited at least one episode of LOS, 31 (2.7%) a VAP, and 44 (3.8%) a MODS. Those infants with complications were of younger gestational age (p<0.001), had lower birth weight (p<0.001), lower Apgar scores at 1/5/10 minutes (p<0.001), were more common SGA (p=0.007), had longer courses of mechanical ventilation and longer hospital stays and for longer time parenteral antibiotics (all p<0.001). Mortality rate was increased in infants having experienced complications (6.9 vs. 1.7%, p<0.001).

Conclusions. Over an 11-year period, the use of the probiotic LCR as part of an anti-infective regimen was safe and resulted in low rates of NEC, LOS, VAP, and MODS compared to the literature. Those infants with complications had higher mortality rates.

Key words: very preterm infant, probiotics, Lactobacillus casei rhamnosus, necrotizing enterocolitis, multiple organ dysfunction syndrome, neonatal intensive care, ventilator associated pneumonia, late-onset sepsis, antibiotic-associated diarrhea 

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The Importance of Bedside Ultrasonography in Confirming the Location of Endotracheal Tube


Objective. Endotracheal intubation may be associated with lethal complications when not applied in appropriate manner. In this study, we aimed to examine the efficiency of transcricoid and pulmonary ultrasonography in confirming the position of the tube in comparison with classical methods.

Methods. This study was carried out between 2016 and 2017 in Turkey and was registered in Clinical Trials under number NCT03081221. The location of the tube was confirmed using methods such as monitoring the vocal cords during direct laryngoscopy, condensation on endotracheal tube during respiration, epigastric-pulmonary auscultation, radiography and capnometry. After that, the transcricoid and pulmonary ultrasonography were implemented by the blinded pediatric emergency care specialist.

Results. 64 cases who needed advanced airway requirements were involved in this study. The double-line appearance could not be obtained from one patient only when using transcricoid ultrasonography, but the bilateral pleural shift movement was observed among all the cases by using pulmonary ultrasonography (sensitive: 98%-100%).

Conclusion. The determination of endoesophageal, endotracheal and endobronchial intubations can be easily made by using transcricoid and pulmonary ultrasonography. The use of ultrasonography may significantly contribute to critical airway management as fast, accurate and on time.

Keywords: Endobronchial intubation, Endotracheal intubation, Ultrasonography.

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Serum Irisin Levels in Patients with Acute Atrial Fibrillation


Objective: The purpose of this research was to investigate whether changes in serum irisin levels can represent a marker of altered energy requirements in patients with acute atrial fibrillation (AF) undergoing cardioversion (CV).

Methods: The research was planned as a randomized, prospective case-control study. Patients presenting to the emergency medicine and cardiology departments of a university hospital due to acute AF were included in the study. Irisin levels were measured from serum specimens collected 24 and 72 hours (h) following restoration of sinus rhythm with CV in patients in AF rhythm. The values obtained were then compared using statistical analysis.

Results: Thirty-one patients undergoing CV due to acute AF were enrolled. Mean irisin levels were studied from serum specimens collected 24 and 72 h following restoration of sinus rhythm with CV, and were then compared. No statistically significant difference was determined at comparison of patients’ basal to 24 h, basal to 72 h, and 24 to 72 h mean irisin values (p0.734, p0.958, and p0.643, respectively). Negative correlation was determined between basal serum irisin levels and LDL (r= -0.519, p= 0.002), but no significant correlation was observed with epicardial adipose tissue (EAT) thickness.

Conclusion: We determined no change in serum irisin levels studied 24 h and 72 h following return of normal sinus rhythm after CV from basal serum irisin levels in patients with acute AF. No correlation also was determined between serum irisin levels and EAT thickness.

Key words: Atrial fibrillation, Irisin, Epicardial adipose tissue, Cardioversion

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