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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Author: Signavitae (Page 2 of 82)

Hypoxia during one lung ventilation in thoracic surgery


Background. The technique of one lung ventilation (OLV) is used with the purpose of achieving isolation of the diseased lung being operated upon, using a double-lumen endobronchial tube. Thoracic surgical procedures which are performed in the lateral decubitus position, nowadays could not be imagined without OLV. In spite of advantages regarding surgical exposure, OLV is associated with serious respiratory impairment. Hypoxemia is considered to be the most important challenge during OLV. The goal of this study was to establish the magnitude of intrapulmonary shunt, as well as the immensity of hypoxia during general anesthesia with OLV.

Materials and Methods. In this prospective interventional clinical study thirty patients were enrolled who underwent elective thoracic surgery with a prolonged period of OLV. The patients received balanced general anesthesia with fentanyl/propofol/rocuronium. A double-lumen endobronchial tube was inserted in all patients, and mechanical ventilation with 50% oxygen in air was used during the entire study. Arterial blood gases were recorded in a lateral decubitus position with two-lung ventilation, at the beginning of OLV (OLV 0) and at 10 and 30 min. (OLV 10, OLV 30, respectively) after initiating OLV in all patients. Standard monitoring procedures were used. Arterial oxygenation (PaO2), arterial oxygen saturation (SaO2) and venous admixture percentage – intrapulmonary shunt (Qs/Qt %) were measured, as well as mean arterial pressure and heart rate during the same time intervals. For the purpose of this study, the quantitative value of Qs/Qt% was mathematically calculated using the blood gas analyser AVL Compact 3. A p value <0.05 was taken to be statistically significant.

Results. When OLV was instituted, arterial oxygenation decreased, whereas Qs/Qt% increased, about 10 min. after commencement, with improvement of oxygenation approximately half an hour afterwards. A statistically relevant difference (p<0.05) occurred in PaO2, SaO2 and Qs/Qt at the different time points.

Conclusion. Hypoxia during OLV, with an increase in Qs/Qt, usually occurs after 10 min. of its initiation. After 30 min, the values of the Qs/Qt ratio regularly return to normal levels.

Key words: one-lung ventilation, thoracic surgery, venous admixture, intrapulmonary shunt

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Impact of gestational age at PPROM on the short-term outcome of children born after extreme and prolonged preterm prelabor rupture of membranes in an experienced care center


Introduction. Survival of infants born after extreme PPROM (preterm prelabor rupture of membranes) has increased dramatically in the past 20 years, up to 90% in some tertiary neonatal centres, due to the progress in neonatal cardiorespiratory management.

Known risk factors of poor outcomes are lower gestational age at PPROM and prolonged and severe oligohydramnios.

Methods. We performed a retrospective study over a 6-year-period (2009-2015), including 14 pregnant women who experienced PPROM, before 25 weeks of gestation, with prolonged (>14 days) and severe oligohydramnios (amniotic fluid index<5). Each live neonate was matched with a control patient who was born the same year, of the same gender, with the same gestational age (+/- 6 days) and who received treatment to induce fetal lung maturation at least 48 hours before birth.

Results. Live birth rate was 14/20 (70%) and neonatal survival was 13/14 (93%). Apgar scores at 5 and 10 minutes were lower in the PPROM group (p<0.01). Intubation was necessary for all babies with PPROM and for 5/13 (38%) of the controls (p < 0.01). In a subgroup analysis of the PPROM group, we found that all babies with PPROM < 20 weeks presented refractory hypoxemia and required iNO (inhaled nitric oxide) administration compared to one in the PPROM group > 20 weeks (p < 0.01).

In all infants requiring iNO, the oxygenation index improved dramatically and rapidly with treatment.

We found no difference in the rate of bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity or intraventricular hemorrhage.

Conclusion. PPROM before 20 weeks of gestation exposes the neonate to a high risk of refractory hypoxemia compared to PPROM after 20 weeks. The initial care management requires more aggressive treatment with administration of iNO in all of them.

After the initial period, the evolution of all babies born after PPROM is comparable to that of their controls.

Key words: preterm prelabor rupture of membranes, oligohydramnios, pulmonary hypertension, pulmonary hypoplasia.

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The burden of Candida species colonization in NICU patients: a colonization surveillance study


Fungal infections are an important cause of morbidity and mortality in neonatal intensive care units (NICUs). The identification of specific risk factors supports prevention of candidemia in neonates. Effective prophylactic strategies have recently become available, but the identification and adequate management of high-risk infants is still a priority. Prior colonization is a key risk factor for candidemia. For this reason, surveillance studies to monitor incidence, species distribution, and antifungal susceptibility profiles, are mandatory. Among 520 infants admitted to our NICU between January 2013 and December 2014, 472 (90.77%) were included in the study. Forty-eight out of 472 (10.17%) patients tested positive for Candida spp. (C.), at least on one occasion. All the colonized patients tested positive for the rectal swab, whereas 7 patients also tested positive for the nasal swab. Fifteen out of 472 patients (3.18%) had more than one positive rectal or nasal swab during their NICU stay. Moreover, 9 out of 15 patients tested negative at the first sampling, suggesting they acquired Candida spp. during their stay. Twenty-five of forty-eight (52.1%) colonized patients carried C.albicans and 15/48 (31.25%) C.parapsilosis. We identified as risk factors for Candida spp. colonization: antibiotic therapy, parenteral nutrition, the use of a central venous catheter, and nasogastric tube. Our experience suggests that effective microbiological surveillance can allow for implementing proper, effective and timely control measures in a high-risk setting.

Key words: Candida, surveillance, NICU

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Respiratory disorders and neonatal outcomes of triplet pregnancies – our ten year experience


Objective. To compare respiratory disorders (respiratory distress syndrome, requirement for respiratory support, development of chronic lung disease), duration of hospitalization and other neonatal outcomes between newborns born from triplet pregnancies over a ten year period.

Methods. A retrospective analysis of 34 triplet pregnancies delivered between 2006 and 2015 in one perinatal tertiary centre. Ninety-nine newborns from these pregnancies were divided into 2 groups: one consisted of 56 neonates (19 sets of triplets) born between 2006 and 2011 and the second contained 43 neonates delivered from 15 triplet pregnancies between 2012 and 2015.

Results. There were no differences in the incidence of respiratory distress syndrome and chronic lung disease between group I and group II. In both groups, a similar amount of patients required respiratory support. We did not notice any significant differences in the type of ventilation (mechanical ventilation or nasal continuous positive airway pressure -nCPAP), duration of ventilation, length of hospitalization or the incidence of complications of prematurity, such as 3rd or 4th grade intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP) stage > 2, between both groups.

Conclusion. Despite important progress in perinatal care and wide use of advanced technologies in neonatal intensive care there has been no significant improvement in neonatal outcomes of triplets during the past 10 years. Multiple pregnancies still remain a risk factor for respiratory disorders and other neonatal complications in prematurely delivered newborns.

Key words: triplets, newborn, respiratory disorders, outcome

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Estimating poisoning substance amounts: Comparative study of the accuracy of health care professionals and non-practitioners


Objective. Intentional or unintentional substance intoxications are common in patients presenting to the Emergency Department (ED). When we treat intoxicated patients, it is important to know the amount of drug ingestion. We invested the actual amount of semi-quantitative term expressed by patients, and investigated the accuracy of amount estimates by the public and healthcare professionals.

Participants and interventions. 200 volunteers (86 health care providers and 114 non-practitioners) participated. Participants grabbed the 3 types of tablets (5mm, 10mm, and 15mm) in handfuls and fistfuls and estimated the tablet amounts. Actual amounts were measured. 100 volunteers (58 health care providers and 41 non-practitioners) participated in the investigation of accuracy of liquid amount estimation. Participant ingested water in 2.6 cm diameter bottle in response to request to take 1 sip, 1 mouthful, and 3 sips.

Results. The estimated tablet counts became more accurate in terms of both fistfuls and handfuls as the size increased within the same shape classification. Participants tended to underestimate the counts of oval-shaped tablets to a greater extent than round tablets of the same size. The estimated liquids both groups of participants tended to underestimate the amounts but both groups overestimated the volumes when drinking 3 continuous sips. In tablets and liquids, there were no statistically significant differences in accuracy between the groups.

Conclusions. When approaching intoxicated patients who have visited emergency department (ED), treatment should be implemented based on the assumption that the actual ingested amounts are higher than the amounts estimated by patients.

Key-words: intoxication, tablets, amount, estimation, liquids

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