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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Can echocardiographic assessment of interatrial septum shape and motion improve the accuracy of the BLUE protocol?

Abstract

Acute respiratory failure is one of the most challenging critical conditions due to a wide variety of differential diagnosis. Bedside lung ultrasound in emergency (BLUE) protocol allows accurate differentiation between the most common underlying causes of acute respiratory failure in up to 90% of the cases. The assessment of left atrial pressure affecting left ventricular filling is essential in critically ill patients guiding volume substitution, optimization of left ventricular function and prevention of pulmonary congestion, thus ensuing haemodynamic stability. A simple, non-invasive method of left atrial pressure evaluation is the echocardiographic assessment of interatrial septum shape and motion, which is affected by interatrial pressure gradient. Aiming to improve the accuracy of the BLUE protocol, we propose the simple, non-invasive echocardiographic assessment of interatrial septum shape and motion as an upgrade, providing additional information of the loading of left and right atrium thus distinguishing the most common causes of acute respiratory failure.

Key words: lung ultrasound, BLUE protocol, interatrial septum, echocardiography

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Do Inhalational Anesthetic Agents Still Hold Their Place in Modern Anesthesia Practice?

Abstract

Inhalational anesthetic agents are chemical substances that are administered into the body via lungs and distributed to organs and tissues by blood circulation. The main site of their action is the brain, but they also affect other parts of central nervous system. Volatile and intravenous anesthetics alike have nearly reached the characteristics of an ideal anesthetic, but at a first glance, the increase in use of intravenous anesthetics could likely push out their volatile counterparts. Looking at the situation more thoroughly, positive side effects of volatile anesthetics that are not found in their intravenous counterparts, still give them a place in modern anesthesia practice. It is also possible to combine both techniques to reduce negative adverse effects, while making use of the positive ones.

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A prognostic value of early urinary biomarkers NGAL and IL-18 in critically ill children: a 10-year literature review

Abstract

Introduction. Acute kidney injury (AKI) is a life-threatening syndrome caused by a sudden and rapidly progressing impairment of renal function. It is a common and complicated clinical entity among hospitalized children, occurring in 2%-4.5% of children treated in a pediatric intensive care unit. Mortality among such patients remains high (from 8% to 89%) despite improving patient care and technical possibilities. The stage of renal damage is a reversible process, and its timely detection would prevent the progression of renal damage and thus reduce pediatric mortality rates. Therefore, modern medicine necessitates the identification of novel AKI biomarkers that would correlate with renal cell damage and could be detected earlier than a rise in serum creatinine (sCr). Neutrophil gelatinase-associated lipocalin (NGAL) and interleukin 18 (IL-18) are one of such early markers of AKI.

Aim. To carry out a literature review of studies on changes in NGAL and IL-18 levels in the urine of critically ill patients and to determine a prognostic value of these biomarkers in the detection of renal injury and impact on disease outcomes.

Material and methods. This literature review includes the publications of biomedical studies assessing early biomarkers of AKI in urine (uNGAL or uIL-18) of critically ill children, published in English during the 10-year period. Search for publication was performed in the PubMed database.

Results. Analysis included 10 studies that investigated early biomarkers of AKI (NGAL or IL-18) in urine of critically ill children and compared them with sCr. Among the biomedical studies analyzed in our literature review, 9 measured the NGAL level in urine or both in urine and serum, while 2measured IL-18 in urine. It was determined that uNGAL and uIL-18 were good early diagnostic biomarkers of AKI, which increased 48 h earlier than Cr in serum (P<0.005). The meta-analysis carried out by Haase et al. showed that uNGAL predicted the development of AKI better in critically ill children than in adults (OR, 25.4; ROC, 0.930 vs. OR, 10.6; ROC, 0.782). Three studies reported that the uNGAL level in study populations with AKI directly depended on disease severity and AKI degree (P<0.005). Four studies found that uNGAL and one study that uIL-18 are good predictive factors of mortality (P<0.005).

Conclusions. uNGAL and uIL-18 are early predictive biomarkers of AKI in critically ill children. uNGAL and uIL-18 level correlated well with disease severity and are independent predictive biomarkers of mortality.

Key words: acute kidney injury, critically ill children, biomarkers, uNGAL, uIL-18.

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Can partial splenectomy preserve humoral immunity in pediatric patients?

Abstract

The spleen plays an important role in removing normal and abnormal cells from the blood and in providing an immunologic response to encapsulated bacteria. Surgical splenectomy provides effective treatment for several pediatric disorders, such as congenital and acquired hemolytic anemias, abdominal traumas and immunological and metabolic disorders, but it is associated with an immediate and lifelong risk of overwhelming infection. An alternative to conventional splenectomy is partial splenectomy, recommended especially in children younger than 5 years of age. Recommendations for the prevention of overwhelming post-total splenectomy infection include: Pneumococcal, Haemophilus influenzae type B and Meningococcal immunizations, antimicrobial prophylaxis and prompt antibiotic treatment of acute febrile illness; conversely, there is no clear evidence indicating which prevention measures are to be performed in patients undergoing partial splenectomy.

Key words: partial splenectomy, children, immunization

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The application of ex utero intrapartum treatment (EXIT) procedure for cardiothoracic disorders

Abstract

The ex utero intrapartum treatment (EXIT) procedure was primarily developed to reverse temporary tracheal occlusion in patients with fetal surgery for congenital diaphragmatic hernia. Nowadays, it is widely used to resect fetal neck masses and to maintain an unobstructed airway. It is indicated for the management of several cardiothoracic diseases, including mediastinal or lung mass resection, drainage of pleural effusions, palliative treatment of critical congenital heart disease and establishment of EXIT-to-extracorporeal membrane oxygenation (ECMO). EXIT has been attempted successfully in many centers, and it has been proven that mothers and babies tolerate the procedure well. Maternal and fetal surveillance during anesthesia is important to maintain maternal blood pressure and placental blood flow and fetal oxygenation. The aim of this article is to discuss the application of the EXIT procedure for the management of fetal cardiothoracic diseases.

Key words: anesthesia, fetus, mediastinal neoplasms, pleural effusion

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