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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: April 2014 (Page 1 of 4)

How to distinguish between surgical and non-surgical pneumoperitoneum?

Abstract

Not all cases of pneumoperitoneum found on abdominal X-ray or computed tomography (CT) scan are caused by hollow viscus perforation. Non-surgical or spontaneous pneumoperitoneum is a repeatedly described entity. However, not all physicians in emergency departments are aware of it, and in such cases unnecessary laparotomy is often performed which reveals no intra-abdominal pathology. Non-surgical pneumoperitoneum can have thoracic, abdominal, gynecological, or other causes. When we acknowledge the possibility of non-surgical pneumoperitoneum, the primary goal is to discern surgical from non-surgical pneumoperitoneum. Identifying cases in which laparotomy can be avoided is important to prevent unnecessary surgery and its associated morbidity and financial costs. In this paper we propose a practical algorithm which may help the attending physicians to distinguish between surgical and non-surgical pneumoperitoneum.

Key words: non-surgical pneumoperitoneum, postoperative pneumoperitoneum, positive end-expiratory pressure, endoscopy, percutaneous endoscopic gastrostomy, peritoneal dialysis, postcoital pneumoperitoneum

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Decreasing mortality with drotrecogin alfa in high risk septic patients A meta-analysis of randomized trials in adult patients with multiple organ failure and mortality >40%

Abstract

Objective. Sepsis is a complex inflammatory disease, rising in response to infection. Drotrecogin alfa, approved in 2001 for severe sepsis, has been withdrawn from the market. The aim of this study was to assess if drotrecogin alfa-activated can reduce mortality in the more severe septic patients.

Methods. We searched PubMed, Embase, Scopus, BioMedCentral, and in Clinicaltrials. gov databases to identify every randomized study performed on drotrecogin alfa-activated in any clinical setting in humans, without restrictions on dose or time of administration. Our primary end-point was mortality rate in high risk patients. Secondary endpoints were mortality in all patients, in patients with an Acute Physiology and Chronic Health Evaluation (APACHE) 2 score ≥ 25 and in those with an APACHE 2 score ≤25.

Results. Five trials were identified and included in the analysis. They randomized 3196 patients to drotrecogin alfa and 3111 to the control group. Drotrecogin alfa was associated with a reduction in mortality (99/263 [37.6%] vs 115/244 [47.1%], risk ratios (RR) = 0.80[0.65; 0.98], p = 0.03) in patients with multiple organ failure and a mortality risk in the control group of >40%, but not in the overall population or in lower risk populations.

Conclusions. In high risk populations of patients with multiple organ failure and a mortality of >40% in the control group, Drotrecogin alfa may still have a role as a lifesaving treatment. No beneficial effect in low risk patients was found. An individual patient meta-analysis including all randomized controlled trial on sepsis is warranted, along with new studies on similar drugs such as protein C zymogen.

Key words: sepsis, shock, intensive care, critically ill, mortality, drotrecogin alfa, recombinant human activated protein C

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The influence of different airway management strategies on chest compression fraction in simulated cardiopulmonary resuscitation, provided by paramedics: LMA Supreme versus Endotracheal Intubation and Combitube

Abstract

Introduction. It is strongly advised by the European Resuscitation Council not to interrupt chest compressions for airway management. An alternative to tracheal intubation is the use of a supraglottic airway device (SAD) which should shorten “hands-off” time during cardiopulmonary resuscitation (CPR). Chest compression fraction (CCF) should be above 0.6 to ensure the probability of successful CPR. We compared the performance of airway management during CPR provided by

paramedics using the laryngeal mask (LMA) Supreme, Combitube and endotracheal intubation (ET) in a manikin model.

Materials and Methods. Thirty sophomore students of emergency medicine school for paramedics took part in the study. The primary endpoint was to assess the influence of the type of airway management on CCF. The time to successful airway management (TA) was measured and the minute ventilation was assessed using the respirator Medumat Easy and program AMBU® CPR SOFTWARE during uninterrupted CPR. CCF was measured using CPRmeter – QCPR (Laerdal).

Results. Mean CCF was significantly better for LMA Supreme (0.8 vs 0.71 vs 0.65), mean TA was significantly shorter for LMA supreme: 16.5 sec vs 24.37 sec vs 28,3 sec, the success rate in the first attempt was 100% vs 66.6% vs 100%, mean air leak during chest compressions was 14% vs 8% vs 15% for LMA Supreme, ET and Combitube respectively.

Conclusion. The LMA Supreme is an effective tool for airway management during chest compression and provides adequate ventilation.

Key words: cardiopulmonary resuscitation, airway management, endotracheal intubation, supraglottic devices

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Dose pre-hospital laryngeal mask airway use has a survival benefit in non-shockable cardiac arrest?

Abstract

Background. Whether pre-hospital laryngeal mask airway (LMA) use poses a survival benefit and should be approved as routine airway management in non-shockable cardiac arrest is of major concern. The present study examined the effectiveness of LMA, in comparison to other pre-hospital airway management on individuals who have experienced non-shockable cardiac arrest.

Methods. Adult patients who experienced non-shockable cardiac arrest with activation of the emergency medical service (EMS) made up our study cohort in Taoyuan, Taiwan. The data were abstracted from EMS records and cardiac arrest registration protocols.

Results. Among the 1912 enrolled patients, most received LMA insertion (72.4%), 108 (5.6%) bag-valve-mask (BVM) ventilation, 376 (19.7%) high-flow oxygen non-rebreather facemask, and only 44 (2.3%) received endotracheal tube intubation (ETI). With regard to survival to discharge, no significant differences in prevalence were evident among the groups: 2.8% of oxygen facial mask, 1.1% of BVM, 2.1% of LMA, and 4.5% of the ETI group survived to discharge (p = 0.314). In comparison to oxygen facial mask use, different types of airway management remained unassociated with survival to discharge after adjusting for variables by logistic regression analysis (BVM: 95% confidence interval [CI], 0.079 – 1.639 [p = 0.186]; LMA: 95% CI, 0.220–2.487 [p = 0.627]; ETI: 95% CI, 0.325–17.820 [p = 0.390]). The results of Hosmer-Lemeshow goodness-of-fit test of logistic regression model revealed good calibration.

Conclusions. Pre-hospital LMA use was not associated with additional survival to discharge compared with facial oxygen mask, BVM, or ETI following non-shockable cardiac arrest.

Key words: emergency medical service, out-of-hospital cardiac arrest, laryngeal mask airway, ventilation, cardiopulmonary resuscitation

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Fluid balance in critically ill neonates – ways to improve it

Abstract

Fluid balance is an essential element of intensive care in critically ill neonates. Fluid and electrolyte management is carried out by constant and precise assessment of total fluid intake and output, frequent laboratory monitoring and fluid balance documenting. Accurate continuous and controlled intravenous fluid and drug administration via infusion pumps is crucial. One of the greatest “costs” of fluid and electrolyte status monitoring in critically ill neonates is the volume of blood required for its achievement. A significant volume of blood is required for laboratory testing and increases the need for red blood cell transfusions. In our retrospective observational study we evaluated the fluid balance in 30 critically ill neonates admitted to a level III multidisciplinary neonatal and paediatric intensive care unit (ICU) at the University Medical Centre Ljubljana (UMCL), between September 2011 and January 2012. The information generated by this study provided a basis for the improvement of existing management of fluid balance in critically ill neonates.

Key words: fluid balance, critically ill neonate, surgical, non-surgical

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