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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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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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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Pediatric ischemic stroke – an unlikely diagnosis: a report of three cases


Pediatric ischemic stroke is a rare and devastating disease. A patient presenting with acute neurological deficit should raise suspicion of a possible stroke. However, stroke “mimics” account for a majority of suspected stroke cases in childhood. We present three cases of pediatric acute ischemic stroke, two of which are arterial, and one caused by thrombosis of venous sinuses. In the first case, we present a 16-year old male patient was admitted to our hospital due to a rare Artery of Percheron occlusion. The second case represents a 17-year old female patient with thrombosis of multiple cerebral venous sinuses, venous infarctions and secondary hemorrhages. As the third case, we present 6-year old male patient with a herpes simplex infection and a vertebrobasilar stroke. All three patients had experienced an altered mental status and other nonspecific symptoms. Due to its rarity, diverse clinical presentation, and lack of randomized control trials regarding treatment, ischemic stroke poses a great challenge to pediatricians.

Keywords: Pediatric ischemic stroke, stroke, acute ischemic stroke, thrombosis

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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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Vasoactive-inotropic score as a predictor of in-hospital mortality in out-of-hospital cardiac arrest


Background: The Vasoactive-Inotropic Score (VIS) is an objective clinical tool used to quantify the need for cardiovascular support in children and adolescents after surgery and to predict prognosis of pediatric septic shock. Considering the post-cardiac arrest syndrome (PCAS) is a sepsis-like syndrome, we aimed to investigate the correlation between VIS and in-hospital mortality in out-of-hospital cardiac arrest (OHCA) patients who achieved a sustained return of spontaneous circulation (ROSC) and admitted to the intensive care unit (ICU).

Methods: A retrospective chart review of 504 OHCA patients who were admitted to the emergency room with OHCA from Jan 2015 to Dec 2016 was done. VIS was calculated with the recorded administration rate of the drugs on electronic medical record at the same time during the first 24 hours in ICU. The highest value of VIS in 24 hours (24hr-peak VIS) was used for investigating the correlation between VIS and in-hospital mortality.

Results: Among 504 OHCA patients, 166 patients were admitted to the intensive care unit and 116 patients died during hospital stay. The probability of in-hospital mortality was significantly higher when 24hr-peak VIS was higher than 33.3 [Odds ratio (OR) = 3.18, 95% CI = 1.22 – 8.29, p value = 0.018].

Conclusion: 24hr-Peak VIS could be a good scoring system for predicting in-hospital mortality in OHCA patients who admitted to ICU. The AUC was 0.762 (95% CI = 0.690 to 0.825) and the optimal cut-off values were 33.3 (sensitivity 0.764, specificity 0.610).

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