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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Month: April 2018

Do we need an individual approach to atrial fibrillation and adrenergic overload in the critically ill?


Despite catecholamines being lifesaving drugs, they can also be harmful. Adrenergic overload is one of the major promoters of supra- and ventricular arrhythmias, which induce hemodynamic instability in the critically ill. In this paper we will focus on the pathophysiology of atrial fibrillation (AF), the importance of adrenergic overload for triggering AF, the importance of the autonomic nervous system and finally, we will challenge the importance of decreasing adrenergic load with selective and non-selective β-blockers, which have different effects on the metabolism in the severely ill. We will also emphasize the importance of an individual approach due to pharmacogenetic differences in β-adrenergic signalling.

Key word: catecholamine, atrial fibrillation, beta-blocker, metabolism, resting energy expenditure

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Neuromuscular blockade in clinical practice in paediatric anaesthesia: retrospective cohort trial in a tertiary paediatric anaesthesia centre


Background. Neuromuscular blockade is associated with improved airway conditions for intubation and superior conditions for surgical interventions (predominantly important in laparoscopic surgery). Residual neuromuscular blockade in the postoperative period is, according to recently published data, associated with a negative impact on perioperative morbidity and mortality.

Aim. The aim of the study was to describe daily practice in clinical paediatric anaesthesia in a tertiary children’s hospital.

Methods. Data from anaesthesiology records during the period 1.1.2016 to 31.12.2016 were retrospectively screened. Primary outcomes included the rate of surgery cases with neuromuscular blockade, the incidence of cases with perioperative neuromuscular blockade monitoring and the incidence of neuromuscular pharmacologic block reversal. Secondary outcomes were myorelaxant usage according to the age of patients and duration of surgery.

Results. Overall 8046 paediatric patients underwent general anaesthesia in the study period. Muscle relaxants were administered in 1650 cases (20.5%). The most frequently administered muscle relaxant was mivacurium (48.2 %, n=795), followed by cis-atracurium (36.4 %, n=601), suxamethonium (10.3 %, n=170) and rocuronium (7.0 %, n=115). Neuromuscular blockade monitoring was used only in 2.5% (n=41) of cases. Active neuromuscular blockade reversal was administered in 5.8% (n=95) of cases.

Conclusion. Neuromuscular blockade in paediatric anaesthesia was less frequent compared to adults. The low rate of neuromuscular blockade monitoring in combination with the low rate of active block reversal can be considered dangerous due to the relatively high risk of potential residual postoperative blockade, that can negatively influence clinical outcome.

Key words: neuromuscular blocking agent, paediatric anaesthesia, residual blockade, neuromuscular blockade

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The significance of sTREM-1 as a diagnostic biomarker of sepsis in the context of Sepsis-3 definition


Aim. Sepsis remains the leading cause of mortality in spite of advanced diagnostics. The aim of the study was to test the diagnostic value of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in the context of a new definition of sepsis.

Methods. The study was conducted on 41 patients who were suspected of having sepsis according to SIRS (Systemic Inflammatory Response Syndrome) criteria or sterile SIRS. 20 healthy volunteer blood donors were the control group (adult patients of both sexes). According to the latest sepsis criteria (Sepsis-3), patients were retrospectively divided into three subgroups: septic patients, patients with SIRS plus infection and patients with sterile SIRS (non-infectious SIRS).

All subjects had concentrations of sTREM-1 determined by the ELISA method (Abcam commercial test, Cambridge, MA, USA). Samples were collected upon admission to hospital and kept at -20°C until laboratory analysis was performed.

Results. Concentrations of sTREM-1 were significantly increased in patients, compared to the healthy population (p=0.021), but there were no significant differences among subgroups of patients (SIRS plus infection vs. sepsis p=0.871, SIRS plus infection vs. sterile SIRS p=0.72, sepsis vs. sterile SIRS p=0.65).

The value of 300pg/mL was determined to be the optimal cut-off. Concentrations of sTREM-1 were significantly higher in septic patients who did not develop Multiple Organ Dysfunction Syndrome (MODS) within the first 48 hours after admission than in those who did.

Conclusion. According to our results, sTREM-1 failed to express significance as a diagnostic biomarker of sepsis, according to the new definition. Also, it seems not to be a valuable marker in differentiation of sepsis and non-infective SIRS.

Key words: sepsis, sTREM-1, SIRS

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Early instrumental predictors of long term neurodevelopmental impairment in newborns with perinatal asphyxia treated with therapeutic hypothermia


Background. Hypoxic-ischemic encephalopathy (HIE) is a leading cause of disability in full-term newborns. Long-term consequences of HIE, even when treated by hypothermia, are not easily predictable.

Aims. To assess the potential role of electroencephalography and neuroimaging parameters as early predictors of neurodevelopmental outcome in HIE newborns treated with hypothermia.

Methods. We retrospectively evaluated 13 HIE patients treated with hypothermia in January 2012-September 2014. We reviewed their amplitude-integrated electroencephalography (a-EEG) at 6, 12 and 24 hours (h), cranial ultrasonography (US) at 12, 72 h and >7 days of life (DOL) and brain magnetic resonance (MRI) performed at 7-28 DOL, according to validated scores. aEEG, US and MRI patterns were correlated to neurodevelopmental outcome at 18-24 months, considered as negative if one of the following was present: Mental Development Index (MDI)<85, motor, visual or hearing impairment.

Results. The severity of a-EEG, US and MRI alterations at each time point was not different according to the outcome. MDI was negatively correlated with aEEG score at 12h (R= -0.571, p=0.04) and with US score at 72h (R= -0.630, p=0.02). A positive correlation was found between aEEG score at 6h and US score at >7DOL (R=0.690, p=0.013). US alterations of the cortical matter at 72h were directly correlated with a-EEG score at 12h (R = 0.606, p=0.028) and 24h (R=0.605, p=0.029).

Conclusions. Early instrumental evaluations, in particular aEEG and US, seem to predict neurodevelopmental outcome at 18-24 months in HIE newborns treated with hypothermia.

Key words: asphyxia, hypoxic-ischemic encephalopathy, hypothermia, newborn

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Unrecognized B line mimicked pneumothorax on M mode ultrasound


Key words: lung ultrasound, B-line, pneumothorax

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