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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Category: Original articles (Page 1 of 33)

Clinical characteristics and mortality of patients in the intensive care unit with and without new-onset arrhythmias


Objective. The aims of this study were to analyze the risk factors for and types of new-onset arrhythmias in ICU (Intensive care unit), and to evaluate their impact on patient outcomes.

Methods. We studied 1051 patients who were admitted to the two general ICUs between December 2013 and February 2016. These patients were divided into two groups: patients with new-onset arrhythmias and patients without new-onset arrhythmias. We compared the risk factors, types and prognoses of new-onset arrhythmias between these two groups.

Results. New-onset arrhythmias were observed in 20.84% (n=219) of 1051 patients. The main risk factors leading to arrhythmias included age, emergency operation, past cardiovascular disease, patients with multiple systemic diseases, acute respiratory distress syndrome, severe sepsis/septic shock, acute renal dysfunction, cardiovascular disease, electrolyte disturbance, patients on ventilators, patients on vasopressors and higher Acute Physiology and Chronic Health Evaluation II scores (APACHE II score) on ICU admission. Multivariate logistic regression revealed that age, emergency operation, severe sepsis/septic shock, cardiovascular disease, electrolyte disturbance, patients on ventilators and those with higher APACHE II scores on ICU admission, were all significantly associated with new-onset arrhythmias. Arial fibrillation was the most frequent arrhythmia. ICU mortality in patients with new-onset arrhythmias was 22.37% (49 out of 219) compared with 3.61% (30 out of 832) in patients without new-onset arrhythmias (p<0.001). Among surviving patients, ICU stay for those with new-onset arrhythmias was longer than those without new-onset arrhythmias (median stay of 10 days versus 5 days, p<0.001).

Conclusion. We found a high prevalence of new-onset arrhythmias in ICU patients. Arrhythmia, especially atrial fibrillation, was a common complication in ICU patients and was associated with increasing length of ICU stay and higher mortality.

Key words: arrhythmia, intensive care unit, critical illness, mortality

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Intracoronary administration of levosimendan in patients with acute coronary syndromes and decreased left ventricular ejection fraction undergoing coronary artery bypass graft surgery


In cardiac surgery patients, intracoronary (IC) administration of levosimendan can provide optimal drug spread, enabling effective manifestation of favorable drug effects and avoiding potentially harmful systemic hypotension. This could be beneficial in acute coronary syndromes (ACS) with decreased left ventricular ejection fraction (LVEF). We present ten cases of IC administration of levosimendan in ACS manifested as ST segment elevation myocardial infarction, non-ST segment elevation myocardial infarction or unstable angina pectoris. All patients underwent coronary artery bypass graft (CABG) surgery, performed as an “off-pump” or “on-pump”/“off-clamp” procedure (latter one with the use of cardiopulmonary bypass on the beating heart). Levosimendan was administered as an IC bolus (125-250 μg) in each coronary artery graft (2-3 grafts). Intravenous (IV) levosimendan infusion continued (0.1-0.2 μg·kg-1·min-1) after graft placements (24-48 h), with IV infusion of norepinephrine (0.1 mg·ml-1), if needed. Cardiac function was assessed using LVEF (%) (Teicholz), thermodilution cardiac index (CI) (ml·m-2), and systemic vascular resistance (SVR) (dynes·sec·cm-5).

Nonparametric Wilcoxon signed-ranks test [presented as median (MED) with interquartile range (IQR)] indicated a significant difference between preoperative vs. immediate postoperative CI, SVR, and LVEF in all cases [2.2 (1.9-2.5) vs. 3.1 (2.9-3.4) ml·m-2, 1173.0 (1062.7-1278.2) vs. 882.5 (763.5-993.0) dynes·sec·cm-5, 44.5 (36.0-46.7) vs. 53.5 (45.7-59.2) %, respectively] (P=0.005), i.e. IC administration of levosimendan was associated with prompt improvement of intraoperative hemodynamics and cardiac contractility. IC administration of levosimendan may be a promising alternative method for improving decreased cardiac function in acute cardiac ischemia, besides necessary surgical revascularization.

Key words: levosimendan, intracoronary, acute coronary syndromes, CABG surgery

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Admission to NICU in air is more likely if nasal High Flow is used for stabilisation in preterm babies compared to face mask CPAP


Objective. To examine the success of stabilisation and the short term outcomes from the routine use of nasal high flow (nHF) on an unselected cohort of babies in the delivery room (DR).

Design. Retrospective single-centre study

Setting. Single-centre neonatal intensive care unit (NICU)

Patients. Infants born at < 32 weeks gestation

Interventions. Stabilisation and transfer to NICU of an unselected cohort of babies using nHF

Main outcome measures. Success of stabilisation defined by successful transfer on nHF and clinical measures of stability at admission to NICU, including oxygen requirement, admission temperature, surfactant requirement, short term outcomes and whether infants were sustained on nHF by 72 hours of age.

Results. There were 133 eligible babies. 54 were commenced on nHF in the DR (Group A), 47 were stabilised by face mask CPAP (continuous positive airway pressure) (Group B), 26 were intubated (Group C); 6 required only minimal respiratory support (Group D). Median maturity varied between the groups (Group A 27+5 weeks, Group B 30 weeks, Group C 26+2 weeks, Group D 31+5). 72% of Group A and 75% of Group B remained on nHF for 72 hours (P=0.82). Fewer babies received surfactant in Group A versus Group B (29% vs 35%; P=0.67), however groups were not matched for maturity differences and Group A were significantly less mature and of lower birthweight (both P<0.001). Group A were significantly more likely to be in air at admission than Group B (P=0.03).

Conclusion. Preterm babies can be successfully stabilised and sustained on nHF. The use of nHF for immediate stabilisation appears to be effective and, in this study, led to significantly more babies being in air on admission to the NICU compared to face mask CPAP stabilisation.

Key words: nasal High Flow cannula, delivery room, stabilisation, premature

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Heart rate variability analysis in acute poisoning by cholinesterase inhibitors


Heart rate variability (HRV) has been associated with a variety of clinical situations. However, few studies have examined the association between HRV and acute poisoning. Organophosphate (OP) and carbamate inhibit esterase enzymes, particularly acetylcholinesterase, resulting in an accumulation of acetylcholine and thereby promoting excessive activation of corresponding receptors. Because diagnosis and treatment of OP and carbamate poisoning greatly depend on the severity of cholinergic symptoms, and because HRV reflects autonomic status, some HRV parameters may be of value in diagnosing OP and carbamate poisoning among patients visiting the emergency department.

Patients who visited the emergency department of the study hospital between September 2008 and May 2010 with the chief complaint of acute poisoning or overdose were included. Cases that involved ingestion of OP or carbamate insecticides were classified as poisoning by cholinesterase inhibitors and compared with other cases of poisoning or overdose. The time-domain analysis included descriptive statistics of R-R intervals and instantaneous heart rates. The frequency-domain analysis used fast Fourier transformation. A Poincaré plot, which is a scatterplot of R-R intervals against the preceding R-R interval, was used for the nonlinear analysis.

Very-low-frequency (VLF) power and the ratio of low-frequency-to-high-frequency power (LF/HF) were the most effective parameters for distinguishing cholinesterase inhibitor poisoning among cases of acute poisoning, with areas under the receiver-operating characteristic curve of 0.76 and 0.87, respectively. Cholinesterase inhibitor poisoning was a significant factor determining VLF power and the LF/HF ratio after adjusting for possible confounding variables, including age over 40, gender, and tracheal intubation.

Frequency-domain parameters of HRV, such as VLF power and the LF/HF ratio, might be considered as potential diagnostic methods to distinguish cholinesterase inhibitor poisoning from other cases of intoxication in the early stages of emergency care.

Key words: electrocardiography, organophosphates, carbamates, poisoning

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Influence of the adequacy of data collection, during two years, in the management of community-acquired pneumonia in emergency departments


Objective. The aim of this study was to analyze whether structured data collection of patients with community-acquired pneumonia (CAP) in the Emergency Department (ED) improves compliance with clinical guidelines regarding inpatient and outpatient treatment and prescription of antibiotics at discharge.
Material and methods. We performed a quasi experimental, multicenter, pre/post-intervention study. The intervention consisted of basic training for the participating physicians and the incorporation of a data collection sheet in the clinical history chart, including the information necessary for adequate decision making regarding patient admission and treatment, in the case of discharge. We analyzed the adequacy of the final destination of patients classified as Fine I-II and antibiotic treatment in patients receiving outpatient treatment, with each participating physician including 8 consecutive patients (4 pre-intervention and 4 post-intervention).
Results. A total of 738 patients were included: 378 pre-intervention and 360 post-intervention. In the pre-intervention group, Fine V was more frequent and patients were older, had more ischemic heart disease, active neoplasms and fewer risk factors for atypical pneumonia. Of the patients with Fine I-II, 23.7% were inadequately admitted and 19.6% of those discharged received treatment not recommended by guidelines. No differences were observed in the target variables between the two groups.
Conclusion. The adequacy of the decision to admit patients with Fine I-II CAP and outpatient antibiotic treatment can be improved in the ED. Structured data collection does not improve patient outcome.

Key words: community-acquired pneumonia, emergency department, antibiotic treatment, adequacy of admission

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