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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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When ˝clinician˝ does not rhyme with ˝communication˝

It is sad to say that communication skills, whether needed by a clinician to give a prognosis to a terrified patient or required by a petrified speaker during a congress presentation, are very often lacking from the modern-day biomedical professional’s armamentarium.

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Chronic fatigue after a night of work in Serbia (our experience)

Working during the night, especially with geriatric patients, has a detrimental effect on the circadian rhythm. (1) This study was approved by the Ethics Committee and Commission for Examining Ethics. The sample was randomly formed and consisted of 1200 nurses. In order to meet ethical standards in research, subjects voluntarily signed the consent form to join the study. The study group consisted of 600 nurses working the night shift with geriatric patients. The control group consisted of 600 nurses working the eight-hour day shift. As a survey instrument, two questionnaires were used.

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Software support for precise analysis of the lung ultrasound comet-tail artifact (B-line)

One of the most significant features of lung ultrasound (LUS) is comet tail artifacts, also called B-lines or “lung rockets”. The causes of such phenomena are fluid-thickened interlobular septa which are the consequence of increased extravascular lung water (EVLW) or pulmonary edema. The B-lines are defined as a discrete, echogenic, vertical, laser-like signal with a narrow origin in the near field of the image. (1) Functionally, they are a sign of dysfunction of the alveolar-capillary membrane and they can be understood as the ultrasonic equivalent of Kerley B lines on X-ray. The sum of the number of B-lines correlates with the amount of EVLW in the lung and in each scanning site (generally 8 sites, 4 on the right and 4 on the left hemithorax) and may be counted from zero to ten. In addition to the estimated EVLW, detection of B-lines by LUS is a very useful tool for the diagnosis of cardiogenic versus noncardiogenic pulmonary edema and for excluding pneumothorax.  However, from a clinical point of view, there are several limitations in the routine detection of B-lines. In critically ill obese patients B-lines are often more difficult to detect and vaguely visible, and sometimes it is tricky to distinguish a B-line from the so-called Z line. When B-lines are numerous, it is not easy to clearly enumerate them, especially when they tend to be confluent and in such cases the distance between B-lines cannot be precisely measured. Also, B-lines are more dynamic than static ultrasound (US) signs and they are therefore partly operator dependent signs. Mainly, for this reason, B-lines are adopted in routine clinical practice as a semiquantitative not quantitative index of EVLW accumulation. (2)

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Temperature to heart rate relationship in the neonate

Key words: neonate, fever, hypothermia, heart rate, neonatal sepsis

In neonatal intensive care, measurement of heart rate is part of every clinical examination and it is used for monitoring hemodynamic status. However, it is influenced by some exogenous and endogenous factors, such as medication, pain, and stress. (1) Similarly, an increased heart rate is a normal physiological response to fever. Heart rate is known to increase by 10 beats per minute (bpm) per degree centigrade increase in body temperature in children. (2) In order to allow physicians to identify patients who have a higher heart rate than would be expected for a given level of temperature, Thompson et al. (3) created temperature specific heart rate centile charts adaptable to children from three months to ten years. Very few data exist on the relationship of temperature and heart rate in younger infants. The only study on this topic so far was performed in an emergency department that included infants up to the age of 12 months, where they found no linear correlation between fever and heart rate in the group of infants younger than two months. (4) To our knowledge no studies have ever addressed this issue in newborns.

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The use of the “Airtraq Laryngoscope” for securing proper positioning of an endotracheal tube during bedside percutaneous dilatational tracheostomy

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method for long-term ventilation of critically ill patients in many intensive care units (ICUs). However, serious complications related to PDT have been reported, including several cases of intraoperative loss of airway with fatal consequences. (1) Generally, this is the result of the required delicate position of the endotracheal tube (ETT) during PDT, with a partially deflated cuff located at the level of the vocal cords. This position of the ETT may lead to accidental extubation and loss of airway during the procedure, especially in difficult patients with a short, bull neck. On the other hand, too deep a position of the tip of the ETT can lead to accidental punction of Murphy’s eye, with impalement of the ETT. (2) Unfortunately, the operator performing the PDT evaluates the correct position of the tip of the ETT on the basis of questionable, indicative, indirect parameters and clinical signs such as: capnography, the curve on the ventilator monitor and respiratory movements of the thoracic wall.

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