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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Testing of potential biomarkers of cerebral ischemia and vasospasm in patients with cerebral aneurysm surgery

Abstract

Biomarkers for the prediction of vasospasm and delayed cerebral ischemia in patients with a ruptured cerebral aneurysm could be helpful.

In this prospective clinical study, endothelin-1, lactate, pCO2, and pO2 were measured in arterial and internal jugular vein blood before, during and after surgical treatment of a cerebral aneurysm, and were tested as potential predictors of neurologic outcome in patients.

Forty-one patients were enrolled in the study, 23 of them were operated on after aneurismal rupture with development of subarachnoid hemorrhage (SAH) and 18 patients were operated on for a nonruptured aneurysm.

All of the involved patients survived. There was no difference in neurologic outcome between those operated on with a ruptured or nonruptured aneurysm.

Endothelin-1 and lactate concentrations as well as pO2 and pCO2 from arterial and venous blood samples and their venoarterial difference did not differ between groups with and without an aneurismal rupture. Venoarterial difference of endothelin-1 concentrations on the day after surgery significantly differed between the groups with favorable and nonfavorable neurologic outcome. Other variables did not show a statistically significant difference.

Significant correlation was found between endothelin-1 and lactate concentrations, suggesting involvement of the same pathophysiological process.

Another interesting finding was lower arterial and venous pCO2 in patients with lower initial Glasgow Coma Scale (GCS) score and higher Hunt Hess score in the phase after extubation.

We can conclude that the measured biochemical parameters did not show sufficient predictive power to be useful for prediction of cerebral vasospasm and neurologic outcome in everyday clinical practice. However, some correlations that do exist between them suggest involvement of the same pathophysiological process.

Key words: cerebral aneurysm, neurosurgery, endothelin-1, biomarkers, delayed cerebral ischemia

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Effects of therapeutic hypothermia and kinetics of serum protein S100B after cardiopulmonary resuscitation

Abstract

Introduction. Post-resuscitation care is regulated by international guidelines. A milestone of these is the application of therapeutic hypothermia (TH). The aims of our study were: to determine the 30-day-mortality for our patients, to monitor the efficacy and effects of TH, and to investigate serum protein S100B – as an early prognostic marker.

Materials and Methods. In our study, 57 patients, treated after cardiopulmonary resuscitation (CPR) on a multidisciplinary intensive care unit, were included. Patients were divided into groups who received and who didn’t receive TH. 30-day-mortality was determined as an end-point. Effects of TH were monitored using statistical analysis according to clinical parameters and laboratory tests. Serum protein S100B levels were measured with ELISA technique on 20 randomised patients at admission and the 1st, 3rd and 5th day after CPR.

Results. Total 30-day-mortality was 74%. TH did not reduced the 30-day-mortality (73% vs. 74%, p>0.05). We found a significant correlation between TH and serum lactate concentration after admission (0h, p=0.006) and at 12 (p=0.045) and 36 (p=0.049) hours after CPR. On the 3rd (p=0.005) and 4th (p=0.043) day after CPR, as a result of TH, platelet count was significantly higher compared to normothermic samples. There was no significant difference in protein S100B levels between the normothermic and TH group and protein S100B levels did not correlate with 30-day-mortality.

Conclusion. Despite recommendations of international guidelines, we cannot prove the beneficial effect of TH, or a correlation of protein S100B levels with a positive outcome.

Key words: cardiac arrest, cardiopulmonary resuscitation, post-resuscitation care, therapeutic hypothermia, protein S100B

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Effects of enteral nutrition on clinical outcomes among mechanically ventilated and sedated patients in the pediatric intensive care unit

Abstract

Objective. To analyze the effects of enteral nutrition on outcomes and complications of critically ill children in the pediatric intensive care unit (PICU).

Design. Retrospective cohort study.

Setting. PICU in a tertiary care academic medical center.

Patients. Patients up to age 17 years who were admitted to the PICU between January 1, 2011, and December 31, 2013.

Interventions. Intubation for more than 48 hours and requiring any sedative medications. Patients with surgical contraindications to feeding were excluded.

Measures and Main Results. A total of 165 patients met inclusion criteria. Both manual review of the electronic health record and automated data capture (whenever technically feasible) were conducted. Data were collected in REDCap software and analyzed using a statistical discovery program. The mean (SD) calorie intake within the first 10 days of PICU admission was 40% (31.9%) of the prescribed calories. Only 67% of the patients had feeding initiated within 48 hours of admission. No significant difference in hospital or PICU length of stay or ventilator-free days was observed in patients who met one-third of their nutritional goals (50.3%) compared with patients who did not (49.7%). Mortality was nonsignificantly higher among patients who did not meet nutritional goals (P=.07). No association was found between higher doses of opioids or benzodiazepines and nutrition tolerance or gastrointestinal complications.

Conclusions. Early adequate enteral nutrition had no statistically significant impact on the short-term clinical outcomes of PICU patients.

Key words: critical illness, deep sedation, energy intake, pediatric intensive care unit, pediatrics, respiration, artificial

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Continuous cardiopulmonary resuscitation training compared to single training by laypersons

Abstract

Background. Compression-Only Cardiopulmonary Resuscitation (COCPR) has been broadly studied during the last few years and specially introduced into lay rescuers’ training. The aim of the study was to compare the quality of COCPR performed by laypersons (Group A) who attended a single cardiopulmonary resuscitation (CPR) training course, and those (Group B) who underwent regular CPR training every 6 months.

Methods. Both groups completed the “Heartsaver CPR AED” course of the American Heart Association. After 30 minutes they were required to perform COCPR on a manikin with a skills reporter system.

Results. Comparing the 76 once only trained laypersons to the 74 continuously trained lay rescuers, we found that average age (20 versus 40 years old), male gender (54% versus 93%), body mass index (BMI) (24.9 versus 27.3 kg/m2) and regular physical exercise (55% versus 36%) proved significant predictors, p<0.01, p<0.01, p<0.01 and p=0.04 respectively. Regarding COCPR-quality, the percentage of efficient chest compressions (43% versus 58%), average depth of compression (45 versus 50 mm) and percentage of error-free compressions (36% versus 50%) indicated a significant statistical difference, with p=0.01, p=0.01 and p<0.01 respectively. However, the average frequency of compressions per minute (121 versus 124), the percentage of correct hand positioning during chest compressions (87% versus 90%) and the average duty cycle (47% versus 45%) did not display a significant difference.

Conclusion. The continuous CPR training group obtained better results regarding quality of chest compressions when compared with single CPR training.

Key words: cardiac massage, cardiopulmonary resuscitation, out-of-hospital cardiac arrest, emergency medicine, resuscitation

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Comparison of the Eosinophil Count to C – reactive protein, Leukocyte Count, and Neutrophil Count for the detection of bacterial infection in ill-appearing children with fever admitted to the Emergency Department

Abstract

Introduction. From late 19th century to the present day, several authors have investigated the value of low eosinophil count as a biomarker of bacterial infection. In this study, we examined the value of eosinopenia for diagnosing bacterial infection in ill-appearing children admitted to the pediatric emergency department.

Methods. Retrospective review of the medical records of children age 1 month to 14 years who appeared ill on admission to the emergency department (ED). Data collected included; C-reactive protein (CRP) level leukocyte, neutrophil, eosinophil counts, results of microbiological tests, radiologic evaluation, and treatment given in the ED. Final outcome data were also collected.

Results. In total, 878 met our case definition and inclusion criteria. 521 patients had confirmed or presumed bacterial infection and 355 patients had presumed or confirmed viral infection. Nineteen patients died; all had bacterial infections. Neutrophil, eosinophil counts and CRP level were independent risk factors for bacterial infection in the multivariate analysis (p<0.05). The receiver operating characteristics (ROC) curves analysis for discriminating bacterial and viral infection showed that the eosinophil count (≤50 cells/μL) (area under the ROC curve [AUROC] 0.671; 95% Confidence Interval [CI]: 0.639-0.702) was similar to the neutrophil count (AUROC 0.655; 95% CI: 0,622-0.686), and CRP level (AUROC 0.710; 0.678-0.740) (p>0.05). The sensitivities of the leukocyte, neutrophil, and eosinophil counts and CRP level were 57.5%, 62.9%, 61%, and 57.1%, respectively. The specificities of them were 59.1%, 63.3%, 67%, and 77.4%, respectively.

Conclusion. In our study population, although the accuracies of eosinophil, neutrophil counts, and CRP level were not enough, they had similar in distinguishing viral from bacterial infection in ill appearing febrile children. By comparison the leukocyte count had limited predictive value.

Key words: eosinopenia, CRP, acute phase reactants, childhood

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