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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: May 2013 (Page 1 of 3)

Targeting the Endocannabinoid System to Treat Sepsis

Abstract

The endocannabinoid system represents a potential therapeutic target in sepsis due to the presence of cannabinoid receptors (CB2) on immune cells. In this review we discuss how various targets within the endocannabinoid system can be manipulated to treat the immune consequences of sepsis. One of the targets outlined are the endocannabinoid receptors and modulation of their activity through pharmacological agonists and antagonists. Another therapeutic target covered in this review is the modulation of the endocannabinoid degradative enzyme’s activity. Modulation of degradative enzyme activity can change the levels of endogenous cannabinoids thereby altering immune activity. Overall, activation of the CB2 receptors causes immunosuppression and can be beneficial during the hyperactivated immune state of sepsis, while suppression of the CB2 receptors may be beneficial during a hypoimmune septic state.

Key words: sepsis, endocannabinoid system, inflammation, immune modulation

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The risk of central line-associated bloodstream infections with different types of central vascular catheters in a multidisciplinary neonatal and pediatric intensive care unit

Abstract

Objective. Central line-associated bloodstream infections (CLABSIs) are a significant cause of morbidity in critically ill neonates and children. The objective of this study was to compare CLABSI rate associated with different types of central vascular catheters (CVCs) in a multidisciplinary neonatal and pediatric intensive care unit (ICU).
Methods. A prospective cohort study was conducted in a multidisciplinary neonatal and pediatric ICU. All patients, admitted between January 1st 2011 and February 29th 2012, requiring a CVC were included and monitored for CLABSI (defined by CDC/NHSN criteria). CLABSI rates were calculated for each type of CVC as CLABSI episodes/1000 catheter-days. CLABSI rates were compared between patients with single and multiple CVCs.
Results. Of the 557 patients admitted, 362 (65%) required insertion of a CVC (4259 patient-days, 3225 catheter-days, CVC utilization ratio 0.76). There were 14 episodes of CLABSI. CLABSI rate was lowest for umbilical catheters (0/1000 catheter-days), followed by short-term noncuffed and nontunneled CVCs (3.1/1000 catheter-days) and peripherally inserted CVCs (8.8/1000 catheter-days). Higher rates were observed with long-term cuffed and tunneled CVCs (15.9/1000 catheter days) and noncuffed, nontunneled CVCs for temporary renal replacement therapy (RRT) (20.0/1000 catheter days). CLABSI rate expressed per 1000 catheter-days was 3.0 and 19.7 for patients with single or multiple CVCs at the same time, respectively.
Conclusion. The use of noncuffed, nontunneled CVCs for temporary RRT and the presence of multiple CVCs at the same time are associated with a significant increase in the rate and risk of developing CLABSI in a multidisciplinary neonatal and pediatric ICU population.

Key words: central line-associated bloodstream infections, nosocomial infections, central vascular catheter, bloodstream infections, pediatric intensive care unit, neonate, child

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Utilization of automated external defibrillators installed in commonly used areas of Japanese hospitals

Abstract

Objective. Since July 2004, it has become legal in Japan for laypersons to use automated external defibrillators (AEDs). We investigated the effect of AED installation in commonly used areas of Japanese Association for Acute Medicine accredited training (JAAM) hospitals.
Methods. In 2008, we sent questionnaires to 419 JAAM hospitals enquiring about the systems, operations, outcome and characteristics of AED usage.
Results. Valid responses were received from 271 hospitals (64.7%). A total of 251 (92.8%) hospitals installed AEDs, mostly in the outpatient departments. These AEDs could also be used by laypersons. Operational responsibility was mostly assumed by the medical emergency center staff. The Engineering Department was in charge of AED maintenance. Of the surveyed hospitals, 65.5% reported having guidelines for usage. The percentages of hospitals which kept records of AED use and outcomes were low. A total of 66.2% reported having a rapid response team and 98.1% provided a non-standardized resuscitation education program. In 68.3% of hospitals, an AED had been used. AEDs were used not only by medical doctors but also by other health professionals. Among the patients who received AED defibrillation, 42.5% survived without neurological deficit.
Conclusion. The utilization of AEDs, installed in commonly used areas of JAAM hospitals, has shown beneficial and effective outcomes for improving the resuscitation and survival of patients who experience in-hospital cardiac arrest. AEDs can be used not only by doctors but also by laypersons, making them more accessible and useful. The strategic installation of AEDs can make hospitals safer.

Key words: automated external defibrillators, commonly used areas, in-hospital

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Safety of Blunt Spinal Injury Patient on Hospital Gurney

Abstract

Objectives. Restraint of patients on a spine board has been used in the past to prevent further spinal cord injury after rescue of patients from the scene of an accident. Removal from the spine board is a routine protocol in many hospitals once the patient has been cleared of spinal injury. However, the benefit of using a spine board, in light-weight motorcycle-related accident victims, has never been studied before.
Materials and methods. A retrospective observational study enrolled patients who had sustained motorcycle-related accidents and were brought to our emergency department (ED). Patients with a Glasgow Coma Scale score lower than 15 and those who died at the ED, or had incomplete data, were excluded. The diagnosis of spinal injury was based upon clinical evaluation and was confirmed by computed tomography, magnetic resonance imaging or X-ray reports, as interpreted by a qualified radiologist. A neurological examination was performed, according to the Standard Neurological Classification of Spinal Cord Injury, directly after arrival and again before leaving the ED.
Results. During the study period, from January 2007 to December 2010, 91 patients with spinal injuries who met the inclusion criteria, consisting of 35 male and 56 female patients with a mean age of 45.44±18.12 years, were enrolled in our study. The scores of the motor and sensory neurological exams did not show any significant change during the ED stay after being placed in a gurney without a spine board (p=0.432).
Conclusions. Removal of the spine board and placement on a hospital gurney sponge is safe in alert patients whose primary examination is completed at the ED.

Key words: motorcycle accident, spinal injury, spine board, emergency department

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Identification of lung sliding: a basic ultrasound technique with a steep learning curve

Abstract

Introduction. One of the basic premises of sonographic lung imaging is the concept of lung sliding. Identification of clear lung sliding excludes pneumothorax (PTx) at that specific local point.
Methods. Fifty-seven 4th year medical students were given a 20-minute lecture on sonographic identification of lung sliding and exclusion of PTx. After the lecture, students were asked to correctly position the probe, identify shown structures and on each attempt (six attempts in a row) state whether lung sliding is present or not.
Results. There were 57 students in the sample. Fifty students (87.7%) successfully positioned the probe (all 4 positions) for PTx identification. All but five students (91.2%) recognized the anatomic structures of the thorax. Mean number of correctly identified cases per student was 5.1 ± 1.1. In 292 (85.4%) cases, the answer was correct. In 298 (87.1%) cases, students were confident in the correct answer. Students who were confident in the right answer gave the right answer significantly more often when compared to others (90.3% vs. 52.3%, p < 0.001). Sensitivity of this method for 4th year medical students was 82.6% and its specificity was 87.9%. For correct identification of lung sliding in the sixth attempt, students on average needed 4.5 correct attempts.
Conclusion. Our study suggests that 4th year medical students with no prior experience in lung ultrasonography can easily acquire knowledge and skills needed to detect thoracic wall structures and identify lung sliding with a high degree of sensitivity and specificity.

Key words: medical students, ultrasonography, pneumothorax

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