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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Rocuronium versus succinylcholine for rapid sequence intubation in patients with bowel obstruction


Introduction. The aim of the study was to determine intubation conditions in the patients receiving rocuronium in comparison to succinylcholine for rapid sequence intubation during the induction of anesthesia for operative management of bowel obstruction.

Methods. In the randomized controlled study 30 adult patients with bowel obstruction undergoing urgent surgery were randomly allocated in two groups. For muscle relaxation the S-group of patients received succinylcholine (1.5 mg/kg) and the R-group rocuronium (1.2 mg/kg). Intubation conditions were evaluated using a grading system according to Viby-Morgenson. Primary outcomes were intubation conditions 1 minute after the application of a muscle relaxant. Secondary outcome measures were heart rate, blood pressure, and pulse oximetry; potassium and myoglobin serum level.

Results. All patients were orotracheally intubated in the first attempt. During induction, we didn’t observe vomiting or aspiration. Overall intubation conditions in the S-group were statistically significantly better than in the R-group. After RSI there was a statistically significant decrease in systolic and diastolic blood pressure in both groups and statistically significant decrease in heart rate in the S-group. After RSI the potassium level in the S-group was significantly higher in comparison to the R-group and serum myoglobin level non-significantly increased in the S-group and statistically significantly decreased in the R-group.

Conclusion. The results show that rocuronium in RSI patients with bowel obstruction enables the same intubation conditions as succinylcholine and the same risk of aspiration which allows succinylcholine replacement and avoidance of its side effects.

Key words: Rocuronium, succinylcholine, rapid sequence intubation, bowel obstruction, intubation conditions

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Neutrophil/lymphocyte ratio and Red blood cell distribution width are independent risk factors for 30-day mortality in Gastrointestinal system bleeding patients


Background. In this study, we aimed to examine demographic and endoscopic features of patients with GI bleeding to determine the factors affecting 30-day mortality.
Method. Patient’s demographic features, laboratory outcomes, comorbidities, drug use, endoscopy outcomes, Glasgow-Blatchford scores, and mortality status were examined. The factors affecting 30-day mortality were investigated.
Results. The mean age of the patients was 58.2±17.4 years, and 72.1% were male patients. 30-day mortality rate was found to be 14.4%. The mean age of patients who died was high (p<0.05). The incidence of mortality was high in the presence of comorbidity, malignancy, and cirrhosis (p<0.05). Systolic blood pressure was low in the patients who died (p<0.05). No significant correlation was found between mortality and gender, symptoms, predisposing factors, lesion type and Forrest score, diastolic blood pressure and heart rate (p>0.05). Urea, neutrophils, red blood cell distribution width / platelet ratio, neutrophil / lymphocyte ratio and RDW levels were high, and hemoglobin level was significantly low in patients with a mortal progression (p<0.05). No significant correlation was found between mortality, and platelet and lymphocyte levels (p>0.05). Glasgow-Blatchford score was significantly higher in patients who died (p<0.05).
Conclusion. Many factors affect 30-day mortality in GI bleeding. It should be remembered that follow-up of patients with an advanced age who have comorbidity and impaired hemodynamics should be kept for long, and that these patients are at a high risk for mortality.
According to our results, NLR and RDW are independent factors that determine the 30-day mortality in upper GI bleeding.

Keywords: emergency, mortality, NLR, RDW

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Assessment of the implementation of step-by-step adult basic life support sequence by emergency medical technicians and drivers during regular annual training


Objective. Evaluation of the efficiency of practicing step-by-step (SBS) BLS/AED (basic life support/automatic external defibrillator) sequence by emergency medical technicians (EMT) and ambulance drivers (AD) working in medical transport teams.

Methods. A prospective two-month study was conducted in which EMTs and ADs working in medical transport teams performed their regular 4-hour annual training (1 h of lectures, 1.5 h of practical training and 1.5 h of testing). Each participant performed SBS of BLS/AED sequences in front of a three-member team of instructors. The implementation of BLS/AED sequence was evaluated by scoring from 0 to 2 (0 – not, 1 – partially, 2 – properly), separately for EMTs, ADs and in total. The final analysis compared a properly implemented SBS sequence (S1-S36) of actions: IA – initial assessment (S1-S10), BLS (S11-S18), AED (S19-S25), RP – recovery position (S26-S32) and FBAO – foreign body airway obstruction (S33-S36) for use by the BLS/AED between EMTs and ADs. The criterion for a completed regular training was at least 47 (65.0%) of the total number of points won for properly implemented procedures.

Results. The study involved 31 EMTs and 63 Ads, regardless of gender and average age, with EMTs having slightly longer work experience (p>0.05). The results of our study show that EMTs are more skilled at IA, cardiopulmonary resuscitation (CPR) and AED, whereas ADs were better at implementing RP and performing the Heimlich maneuver (p<0.001).

Conclusion. Although EMTs and ADs implement SBS BLS/AED procedures correctly and satisfactorily in more than 65.0%, future research should focus on finding more efficient, shorter and cheaper BLS/AED trainings.

Key words: basic life support, step-by-step, sequence, emergency medical technicians, ambulance drivers

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Diagnostic markers of serious bacterial infections in infants aged 29 to 90 days


Objectives: The diagnosis of serious bacterial infection (SBI) is difficult due to a lack of clinical evidence. The purpose of this study was to determine which inflammatory markers can be used to detect SBI in febrile infants.

Methods: This retrospective cohort study included infants aged 29 to 90 days who visited a tertiary hospital emergency department in Korea between July 2016 and June 2018. The diagnostic characteristics of the neutrophil-to-lymphocyte ratio (NLR), procalcitonin (PCT), C-reactive protein (CRP), white blood cell (WBC) count, and absolute neutrophil cell (ANC) count for detecting SBI were described. Their cutoff values were calculated based on receiver operating characteristic (ROC) curve analysis.

Results: Among 528 infants, 199 were finally enrolled. SBI was detected in 68 (34.2%) of these infants. The median values of all investigated diagnostic markers were significantly higher in infants with SBI than the values in those without: WBC (12.72 vs. 9.91 k/μL), ANC (6.28 vs. 3.14 k/μL), CRP (26.6 vs. 2.8 mg/L), NLR (1.29 vs. 0.78), and PCT (0.5 vs. 0 ng/mL). The areas under the ROC curves for discriminating SBI were: 0.705 (95% confidence interval [CI], 0.629-0.781), 0.793 (95% CI, 0.731-0.856), 0.832 (95% CI, 0.775-0.889), 0.722 (95% CI, 0.651-0.792), and 0.695 (95% CI, 0.611-0.780) for WBC, ANC, CRP, NLR, and PCT, respectively. Using a cutoff value of 0.67 for NLR, the negative predictive value was 90.8% for identifying SBI.

Conclusions: CRP was the best single discriminatory marker of SBI, while NLR was the best parameter for considering discharge.

Key words: bacterial infection, urinary tract infection, clinical marker, discharge planning

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Serum cortisol level as a useful predictor of surgical disease in patients with acute abdominal pain


Introduction. The immediate aim should be to identify potentially resuscitative acute abdominal pain that requires prompt investigation or early surgical intervention. We aimed to evaluate whether serum cortisol levels differentiate surgical and non-surgical disease in patients with acute abdominal pain.

Materials and methods. In this prospective cross-sectional study, the primary end-point was defined as differences in serum cortisol levels between surgically and non-surgically treated patients with non-traumatic acute abdominal pain. The secondary end-point was to compare the cortisol levels with defined complete blood count (CBC) parameters in those groups.

Results. One hundred eleven patients with acute abdominal pain were included in the study. Three most frequent diagnoses were nonspecific abdominal pain, acute appendicitis and dyspeptic complaints. Thirty patients were hospitalized and 22 of them were operated. The median cortisol level was 23.13 µg/dl in surgically treated patients and 13.94 µg/dl in non-surgically treated patients (p<0.001). The area under the ROC curve using cortisol to detect surgical disease was 0.750 (95% CI, 0.659-0.827) and the accuracy of cortisol to detect surgical disease was not inferior to defined CBC parameters. A cortisol value of 17.98 µg/dl had a sensitivity of 67.4% and a specificity of 77.3% for surgical disease.

Conclusion. Operated patients had higher serum cortisol levels. High serum cortisol levels may indicate surgical disease at the early stage on admission in ED patients with acute abdominal pain and may be used as a marker in the prediction of acute surgical abdomen.

Key words: abdominal pain, cortisol, emergency department, surgery

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