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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Category: Original articles (Page 1 of 35)

Haemodynamic stability during anaesthesia induction with propofol – impact of phenylephrine. A double-blind, randomised clinical trial.


Background. We studied the effects of a parallel phenylephrine infusion during bispectral index guided anaesthesia induction with propofol on haemodynamic parameters. We hypothesised that mean arterial pressure and cardiac index would be better maintained in the group of patients receiving the phenylephrine infusion during induction.

Methods. We studied ASA I-III patients scheduled for oncological abdominal surgery. Forty patients randomly received either a 0.9% NaCl or a phenylephrine (0.5 μg/kg/min) infusion during the induction of anaesthesia with propofol to a bispectral index value of 60. Mean arterial pressure, stroke volume index and systemic vascular resistance index were recorded, starting at one minute before induction for 20 minutes, at one-minute intervals.

Results. After induction of anaesthesia before intubation mean arterial pressure and stroke volume index decreased significantly compared to baseline in both groups, while the systemic vascular resistance index increased slightly. At the end of measurements, mean arterial pressure (66 11 vs. 94 14 mmHg; 0.9% NaCl vs. phenylephrine group p<0.01) and stroke volume index (34.2 9.1 vs. 44.0 9.7 ml/m2; 0.9% NaCl vs. phenylephrine group p<0.01) were lower in both groups in comparison to baseline values, but were better maintained in the phenylephrine group, whereas systemic vascular resistance index was higher than at baseline (2308 656 vs. 3198 825 dynes s/cm5/m2; 0.9% NaCl vs. phenylephrine group p<0.01) with significant differences between groups.

Conclusion. Our study shows that a continuous phenylephrine infusion can attenuate the drop in mean arterial pressure and stroke volume index during anaesthesia induction with propofol.

Key words: anaesthetics, propofol, monitoring, depth of anaesthesia, consciousness monitors, bispectral index, sympathetic nervous system, phenylephrine, measurement techniques, cardiac output

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One lung ventilation: double-lumen tube with vs. without carinal hook


Background. One lung ventilation (OLV) has become a standard procedure for the vast majority of interventions in pulmonary surgery. The most commonly used are left sided double-lumen tubes (DLTs) which are placed into the left main bronchus and the right or left lung can be isolated.

The aim of our study was to compare DLTs with and without a hook.

Materials and methods. Fifty-four patients undergoing lung resection were included in the randomized, controlled, single-blinded study. Recruited patients were randomly allocated to each group (hook/without hook). Demographic data, procedural data, type of tube used, and difficult intubation criteria were recorded. Complications, according to intubation and position of the tube, were also recorded. After the operation, we aske patients about a sore throat, hoarseness, haemoptysis and their satisfaction with the procedure.

Results. Baseline characteristics were well balanced between groups. Time to place DLT was shorter in the group without a hook (47.7±45.5 vs 15.8±15.1s; P=0.01). The incidence of adequate positioning at the first attempt was higher in the group with a hook and the repositioning rate was higher in the group without a hook (22.22 vs 59.25%; P=0.004). Patients in both groups suffered similar incidences of hoarseness, sore throat or postoperative haemoptysis (5/5/1 vs 3/3/0; P = 0.44). Patient satisfaction was higher in the group without a hook (31.85% vs 34.81%;0.03).

Conclusion. The study showed the advantage of DLTs without a hook in comparison with DLTs with a hook. In our institution we decided to use DLTs without a hook, with fiberoptic control.

Key words: double-lumen tube, carinal hook, pulmonary surgery

Trial registration: NCT02857504

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Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patient


Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.

Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).

Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).

Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube.

Key words: colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia

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Assessment of basic life support skills among medical doctors and technicians in Belgrade emergency medical services


Objective. Our aim was to assess BLS (basic life support) skills among medical doctors (MDs) and medical technicians (MTs) who work at Belgrade Emergency Medical Services (BEMS).

Methods. A prospective study was conducted between 28 September and 9 December, 2016. MDs (Group 1) and MTs (Group 2) attended an accredited course in BLS at BEMS. At the end of the course the participants were given a written test consisting of 20 questions (pass rate 65%). The results were analyzed for each group i.e. profession (Group 1 and Group 2) according to the number of accurate and inaccurate answers to each question. In the end, a number of participants from each group, who answered all 20 questions correctly, were identified. The results obtained, by test analysis, demonstrated the participants’ acquired BLS skills.

Results. The study involved 100 participants (50 in each group). All participants from Group 1 correctly answered questions number 1, 2, 3, 10, 13, 17 and 20. In Group 1 only two participants had three incorrect answers in the test. The largest number of incorrect answers was related to question number 16. Thirty-four participants in this group answered all questions correctly. All participants from Group 2 gave correct answers to questions number 2, 5, 9, 10 and 13. In Group 2, one participant had six incorrect answers and one participant had 5 incorrect answers. The largest number of incorrect answers was related to questions number 3 and 20. Nineteen participants from Group 2 answered all questions correctly. The rate of correct answers between Group 1 and Group 2 was 19.66 : 18.91 (0.75 difference).

Conclusion. The research showed a satisfactory level of knowledge in both groups. However, there is a statistically significant difference in the knowledge of MDs after the BLS course. The results obtained justify the ambitions that all healthcare professionals, regardless of their qualifications, should be trained in applying BLS, both at work and as eyewitnesses.

Key words: basic life support, knowledge/skills, doctors, medical technicians, emergency service

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Medical emergencies in dental offices in Slovenia and readiness of dentists to handle them


Introduction. Dentists, and all other dental healthcare workers, can expect to face a medical emergency directly or indirectly related to dental treatment. This study evaluates the incidence of medical emergencies in dental offices in Slovenia, the readiness of dentists and possession of specific medical equipment.

Methods. An anonymous online based questionnaire was sent through the Medical Chamber of Slovenia via email to all 1503 active dentists in Slovenia. The questionnaire was pilot-tested on 25 dentists and improved accordingly. Thirty closed-ended questions were answered by 289 (19.2 %) dentists.

Results. 93.4 % (n=267) of dentists reported a medical emergency in their dental office. The most prevalent diagnosis was syncope (1.88-2.44/dentist/year) followed by hypoglycaemia (0.20-0.25/dentist/year), hypertensive crisis (0.4/dentists/year) and anaphylaxis (0.3/dentists/year). There were no cardiac arrests reported in the dentists’ entire careers. 85.1 % (n=239) of dentists underwent postgraduate BLS training, 87.4 % (n=209) of them in the last 5 years. Responding dentists estimated that they are most capable of dealing with syncope and least proficient in dealing with stroke, cardiac arrest and a hypertensive crisis. They felt generally more prepared to manage than diagnose a medical emergency. Only 58.1 % (n=161) of dentists have access to a self-inflating bag with a reservoir, and 54.9 % (n=152) to an oxygen mask. Only 4.0 % (n=11) of them have a full set of equipment recommended by Medical Chamber of Slovenia.

Conclusions. Results support modification of the undergraduate and postgraduate curriculum for dental students to address specific medical emergencies and the usage of limited equipment. They support more rigorous regulations concerning postgraduate education and specific equipment for dealing with medical emergencies in dental offices in Slovenia.

Key words: emergencies, dental office, equipment, curriculum

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