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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Transtracheal jet ventilation in a porcine model

Abstract

Hypoxemia is a frequent event during difficult airway management. We propose to use transtracheal jet ventilation (TTJV) early during the management of complex difficult airway scenarios. The objective of this porcine study is to highlight the benefit of oxygenation via prophylactic TTJV. Eighteen pigs (Sus scrofa) were divided into two equal groups. In Group A, pigs were anesthetized and no lung ventilation was conducted following administration of succinylcholine and prior to tracheal intubation. Group B, after induction of anesthesia, received transtracheal ventilation using 100% oxygen. In both groups intubation was performed after waiting 90 seconds. All intubations were achieved in less than 30 seconds. Post-intubation arterial blood gases demonstrated significant hypoxemia in Group A (PaO2 22.6 + 5.8 mm Hg), while in Group B oxygenation substantially improved (PaO2 470.3 + 17.0 mm Hg). The arterial CO2 retention was associated with mild respiratory acidosis (pH 7.26 ± 0.05) in Group A only. These findings prove that prophylactic TTJV can improve oxygenation and allow extra time for definitive management of difficult airway.

Keywords: transtracheal catheter; ventilation, tracheal intubation, difficult hypoxemia

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Measurement of skeletal muscle tissue oxygenation in the critically ill

Abstract

Shock is a state of acutely reduced tissue oxygenation. In cardiogenic shock oxygen delivery (DO2) is reduced, but oxygen extraction is preserved. In septic shock DO2 is preserved, but oxygen extraction is decreased because of microvascular changes and disturbed metabolism. Global assessment of DO2 and oxygen consumption does not tell us enough about adequacy of regional perfusion. The aim of this study was to assess the value of near infrared spectroscopy (NIRS) in detecting skeletal muscle tissue oxygenation (StO2) in critically ill patients.
Patients in cardiogenic shock (n=17), septic shock (n=14), without shock but with localized infection (n=14) and healthy volunteers (n=15) were included. Thenar StO2 was measured with NIRS before (baseline StO2, %), between (downward StO2 slope, %/min) and after 90 seconds of upper arm stagnant ischemia (hyperemic StO2, %). Muscle oxygen extraction (mOER) was calculated as follows: mOER (%) = (1-baselineStO2/hyperemic StO2)*100. Repeatability was assessed using the Bland Altman method (95 % of values within limits of agreement), comparing 55 pairs of measurements performed in 5-minute intervals.
Repeatability of measurements was clinically acceptable. Compared to septic shock patients, cardiogenic shock patients had lower baseline StO2 (68.9 ± 10.0 % vs. 84.3 ± 10.4 %; p < 0.05) and hyperemic StO2 (80.8 ± 7.8 % vs. 91.8 ± 8.3 %; p < 0.05), and a higher downward StO2 slope (-17.4 ± 31.7 %/min vs. -9.1 ± 2.6 %/min; p < 0.05). mOER was higher in healthy volunteers (11.9 ± 3.8 %) and volunteers with cardiogenic shock (14.8 ± 7.3 %) compared to septic shock patients (8.1 ± 7.8 %) and those with localized infection (7.6 ± 5.4 %) (p < 0.05).
Repeatability of baseline StO2 and hyperemic StO2 is clinically acceptable. Results support the hypothesis that skeletal muscle oxygen extraction capability is preserved and extraction is increased in cardiogenic shock compared to septic shock.

Key words: repeatability, NIRS, tissue oxygenation, cardiogenic shock

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Acute isolated sphenoid sinusitis in a 4-year-old child: a rare case with an atypical presentation

Abstract

Acute, isolated, sphenoid sinusitis is unusual, especially in children. Its incidence is about 2.7% of all sinus infections and is even rarer in children under the age of six years. It is frequently misdiagnosed because of its atypical presentation and it can cause serious complications because of the sphenoid sinus’ anatomical relations with many intracranial structures.
We report a case of a previously healthy 4 year old boy, whose sole symptom at presentation was drowsiness. Physical examination and initial laboratory investigations were normal. Diagnosis was made after computed tomography of the head revealed left sphenoiditis. Although under treatment, the child manifested meningism during the first day of hospitalization, which subsided the next day. He was treated with ceftriaxone plus clindamycin and had a good outcome, without complications or neurological sequelae.

Key words: sphenoiditis, intracranial complications, children

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Difficult airway management in the emergency room using an airway scope

Abstract

In the emergency room, some cases need adequate airway management. We present a patient whom we intubated using a new device. This device might be an option in airway management but some considerations should also be taken into account.

Key words: airway management, sco-pe, secretions, bleeding

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