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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Page 3 of 94

A rare consequence of trauma: Chylothorax


Chylothorax is defined as the lymphatic fluid accumulation in the pleural space due to the obstruction or injuries in the ductus thoracicus. The incidence of chylothorax due to blunt and penetrating traumas is low at a rate of 0.2-3%. This case presentation intends to evoke chylothorax as a rare cause of pleural effusion due to injuries.

A 27-day-old infant was brought to the emergency department with the complaint of a sudden respiratory distress developing after falling off the couch. The respiratory rate was 62, the pulse rate was 174, and the oxygen saturation rate was 68%. In the physical examination, the respiratory sounds were diminished bilaterally. The patient was intubated. As the saturation levels did not improve after intubation, a needle aspiration was performed bilaterally in the anterior axillary line with a prediagnosis of massive haemothorax. A yellowish fluid was aspirated from the pleural space bilaterally. Chest tubes were inserted bilaterally to treat respiratory distress due to mass effect of chylothorax. Massive chylothorax cases may result in serious complications leading to respiratory distress and cardiac dysfunction. An early diagnosis and appropriate treatment can be life-saving in these patients.

Key words: chylothorax, trauma, pleural effusion

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Tortuosity of the brachiocephalic artery complicated with arterial injury after tracheotomy: a case report


Tracheotomy is an operation of the airway performed even on critical care patients. Surgical complications of tracheotomies are fatal. In this study, tortuosity of the brachiocephalic artery complicated with arterial injury was observed in a patient after tracheotomy. A 95-year-old woman in coma was admitted to our medical center. The patient needed airway management, and tracheal intubation was performed. The cause of the coma was extensive cerebral infarction of the right middle cerebral artery. It was expected that the coma would be prolonged, and a tracheotomy was performed after 7 days. Tortuosity of the brachiocephalic artery was confirmed with cervical computed tomography before surgery. The patient bled through the tracheostomy after 30 days. To arrest bleeding from the right common carotid artery, a vascular repair surgery was performed. There was no recurrent bleeding after surgery. After 37 days, the patient died of deteriorating primary disease. Although tracheotomy is a common operation, attention should be paid to abnormalities of blood vessels including tortuosity of the brachiocephalic artery.

Key words: arterial injury, brachiocephalic artery, complications, critical care, tracheotomy

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


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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Validation of tracheal intubation of wire-reinforced endotracheal tube with ultrasonography


Objective. The use of ultrasonography (US) is a new method for verifying the location of the endotracheal tube.

Design. Our study was designed as a paired-data and investigator-blind clinical study for evaluating the effectiveness of US for verification of wire-reinforced endotracheal tube (WR-ETT) placement compared with capnography.

Setting. This study was conducted on 56 patients scheduled for elective surgery under general anesthesia.

Patients. Fifty patients completed the study as 6 were excluded for various reasons.

Intervention. Two different investigators performed the ultrasonography and intubation independently from one another. While investigator 1 attempted to verify the location of the WR-ETT with a portable ultrasonography with sagittal trans-tracheal view, investigator 2 intubated the patient and verified the location of the ETT using capnography.

Measurements. Time for verifying the location of the ETT using both US and capnography was recorded.

Main Results. When the ultrasonography method was compared with capnography for verification of the WR-ETT placement, the results showed 95.75% sensitivity and 100% specificity. The average verification times for endotracheal intubation were 12.78 ± 7.46 s. and 24.44 ± 1.45 s. with US and capnography, respectively (p=0.003).

Conclusion. Our results suggest that ultrasound identification of a WR-ETT within the trachea is a rapid and accurate method for confirmation of tracheal placement. Larger studies are needed before widespread use of this technique.

Key words: endotracheal tube, intubation, ultrasonography, capnography

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Ketamine use for endotracheal intubation in severe sepsis and septic shock


Objective. We conducted this study to evaluate the clinical outcomes of patients with severe sepsis and septic shock who were treated with ketamine for endotracheal intubation.

Methods. A single-center, retrospective study was carried out to compare the outcomes of patients with severe sepsis and septic shock who received a ketamine or non-ketamine agent for rapid sequence intubation (RSI). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED), met the criteria for severe sepsis or septic shock, and underwent endotracheal intubation between August 2008 and March 2014. The primary outcome was 28-day mortality. We performed a multivariable logistic regression analysis to assess the association between ketamine use for intubation and 28-day mortality.

Results. In all, 170 patients were intubated during the study period. Of the eligible patients, 95 received ketamine and 75 received a non-ketamine agent. The 28-day mortality of the ketamine group was not significantly different from that of the non-ketamine group (38% vs. 40%, respectively, P=0.78). The unadjusted odds ratio (OR) of ketamine use for 28-day mortality was 0.92 (95% CI: 0.49–1.70, P=0.78). The association remained insignificant after adjusting for age, gender, malignancy, initial lactate level on ED admission, time to first antibiotic administration, Acute Physiology and Chronic Health Evaluation II score on admission day, and propensity score regarding ketamine use (adjusted OR: 1.09; 95% confidence interval [CI]: 0.49–2.40; P=0.84). Initial serum lactate on ED admission was the only significant predictive factor of 28-day mortality (adjusted OR: 1.23; 95% CI: 1.10–1.38; P<0.01).

Conclusions. For patients with severe sepsis and septic shock who were intubated using RSI, we found no significant difference in 28-day mortality between those who received ketamine as a sedative agent and those who received alternative sedatives.

Key words: sepsis, ketamine, intubation, mortality

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