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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Page 2 of 41

Prophylactic use of the probiotic strain Lactobacillus casei rhamnosus as part of a triple anti-infective regimen in very preterm infants during neonatal intensive care


Background. Probiotics are increasingly used in neonatal intensive care and prove to reduce rates of necrotizing enterocolitis (NEC), sepsis and all-cause mortality by meta-analyses.

Objective. Aim of the study was to analyze the prophylactic use of the probiotic Lactobacillus casei rhamnosus (LCR) as part of a triple anti-infective treatment regimen in very preterm neonates in respect to complications and possible side effects.

Setting. This was a study on 1169 very preterm infants of 32 weeks of gestational age and less born between 2005 and 2015 who were admitted within the first 24 hours of life to the neonatal intensive care unit (NICU) and hospitalized for at least 7 days.

Design. Retrospective observational STROBE compliant single-center cohort study

Intervention. All infants received a standardized prophylactic anti-infective treatment regimen with enteral probiotics (LCR), antifungal agents, and oral gentamycin over the study time starting at the first day of life.

Outcome measures. Perinatal and neonatal data were collected for descriptive analysis. Complications possibly avoided by the anti-infective regimen included NEC, late-onset sepsis (LOS), late-onset multiple organ dysfunction syndrome (MODS), and ventilator associated pneumonia (VAP).

Main results. Eleven of 1169 infants 11 (0.9%) had diagnosis of NEC ≥ IIa, 141 (12.1%) exhibited at least one episode of LOS, 31 (2.7%) a VAP, and 44 (3.8%) a MODS. Those infants with complications were of younger gestational age (p<0.001), had lower birth weight (p<0.001), lower Apgar scores at 1/5/10 minutes (p<0.001), were more common SGA (p=0.007), had longer courses of mechanical ventilation and longer hospital stays and for longer time parenteral antibiotics (all p<0.001). Mortality rate was increased in infants having experienced complications (6.9 vs. 1.7%, p<0.001).

Conclusions. Over an 11-year period, the use of the probiotic LCR as part of an anti-infective regimen was safe and resulted in low rates of NEC, LOS, VAP, and MODS compared to the literature. Those infants with complications had higher mortality rates.

Key words: very preterm infant, probiotics, Lactobacillus casei rhamnosus, necrotizing enterocolitis, multiple organ dysfunction syndrome, neonatal intensive care, ventilator associated pneumonia, late-onset sepsis, antibiotic-associated diarrhea 

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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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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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Fluid optimisation in pancreas surgery


Background. Optimal intravascular blood volume, cardiac output and sufficient oxygen supply is a mainstay in major abdominal surgery. Adequate haemodynamic management can improve a favourable outcome and shorten the duration of hospital stay.

Our study anticipated different fluid and vasoactive drug consumption and less complications during the pancreatic surgery in the group of patients where extended haemodynamic monitoring was applied.

Materials and methods. 59 adult patients, ASA 2-3, undergoing elective pancreas surgery, were included in the study. In 29 patients in the study group (SG – extended haemodynamic monitoring), cardiac index (CI), mean arterial pressure (MAP) and nominal stroke index (SI) were maintained within 80% of baseline values with actions following study protocol. Patients’ groups were homogenous, even when divided into 4 subgroups (control group (CG) and without epidural catheter (EC), CG and with EC, SG and without EC, SG and with EC).

Intraoperative variables (amount of fluids, vasopressors, surgery duration) and hospitalisation duration, wound healing, reoperation, mortality and other complication were recorded on the postoperative days 3, 5, 8, 15 and on hospital discharge.

Results. There was no difference in ASA health status, intraoperative management and duration of hospitalisation in 4 subgroups. There is a significant difference in intraoperative use of vasopressor support between 4 subgroups (Fisher exact test, p=0,032). All patients in SG with EC required vasopressors. Number of patients with major complications were not statistically different between groups. Pulmonary embolism, postoperative food intolerance and myocardial infarction have occurred only in CG.

Conclusion. In our study there was no difference in overall fluid and vasoactive drug demand. Although in the studied subgroup of patients with additional epidural anaesthesia there was significantly increased demand for vasoactive drugs. The incidence of complication was low in both groups, however, some of major complications occurred only in CG.

Keywords: haemodynamic monitoring, fluid optimisation, postoperative outcome, pancreatic surgery

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