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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Safe parenteral nutrition and the role of standardised feeds


Workload pressure on pharmacies through increased demands for parenteral nutrition (PN) is leading to a growing trend in the use of commercially manufactured PN (‘standard feeds’) and away from individually ‘tailored’ prescriptions. This is sometimes justified on grounds of safety, although many areas of risk remain inherent in the process of PN provision. In fact there is little to suggest that widespread introduction of standard feeds would do much to further reduce the already low frequency of serious adverse events. The relative clinical benefits of providing standard feeds or tailored feeds have not been adequately studied, making it impossible to give a clear endorsement of one system over the other. It seems probable that for a proportion of stable patients a range of standard feeds could provide adequate nutritional support, while in unstable patients with complex needs and those needing long term PN, tailored feeds appear the more logical choice. Pharmacy compounding units, therefore, need to remain flexible in their approach to PN provision. Since even small variations in nutrient intake in early life may have long lasting implications for extremely premature infants the processes of formulating and providing PN deserve further study.


Key words: parenteral nutrition, standard feeds, pre-mixed PN solution, tailored feeds, premature infants

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Human protein C concentrate in pediatric septic patients


Severe sepsis and septic shock are leading causes of morbidity and mortality in the pediatric population. Unlike what is suggested for the adult population, recombinant human activated protein C (rhAPC) is contraindicated in children. Long before rhAPC was considered for use in pediatric patients, case reports appeared on the safe administration of protein C zymogen. Therefore, we conducted a systemic review of currently available data on protein C zymogen (PC) use among children affected by severe sepsis or septic shock.

A total number of 13 case series or case reports and a dose-finding study were found on the use of PC in the pediatric intensive care unit, reporting on 118 treated children, with an overall survival of 84%. There was no bleeding complication, the only reported complication being a single mild allergic reaction.

These studies show that PC is safe, not associated with bleeding and possibly useful for improving coagulation abnormalities of sepsis.


Key words: sepsis, pediatric, protein C, drug therapy, review

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Vasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis


Objective. A combination of vasopressin and epinephrine may be more effective than epinephrine alone in cardiopulmonary resuscitation (CPR), but evidence is lacking to make clinical recommendations. This meta-analysis compares the efficacy of vasopressin and epinephrine used together versus epinephrine alone in cardiac arrest (CA).

Methods. We searched MEDLINE and EMBASE for randomized trials comparing the efficacy of vasopressin and epinephrine versus epinephrine alone in adults with cardiac arrest. The primary outcome was the return of spontaneous circulation (ROSC) and the survival rate on admission and discharge .We also analyzed ROSC in subgroups of patients presenting with different arrest rhythms, such as asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF).

Results. We analyzed 6 randomized trials out of 485 articles. We did not find evidence supporting the superiority of vasopressin and epinephrine used in combination, except for the survival rate at 24h 2.99 95% CI(1.43,6.28). No evidence supports the conclusion that vasopressin combined with epinephrine is better than epinephrine alone for ROSC, even amongst subgroups of patients.

Conclusion. This systematic review of the efficacy of vasopressin and epinephrine use found that its combined use is better for 24h survival rate but only in one study which included 122 patients. Further investigation will be needed to support the use of this combination for cardiac arrest management.


Key words: cardiopulmonary resuscitation, meta-analysis, epinephrine, vasopressin

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Out-of-hospital cardiopulmonary resuscitation in four Serbian university cities: outcome follow-up according to the “Utstein style”


Aims. To investigate the return of spontaneous circulation (ROSC), survival to discharge, six-month and one-year survival of patients with out-of-hospital cardiac arrest in four university cities in Serbia.
Methods. A prospective, two-year, multicentre study was designed. Using the Utstein template, we recorded out-of-hospital cardiopulmonary (CPR) and its outcomes, and analyzed the immediate survival (ROSC>20 min.), short-term survival (to discharge), long-term survival (one year after discharge), or death following out-of-hospital CPR.
Results. During the study period, 591 patients met the inclusion criteria for enrollment and out-of-hospital CPR. The etiology of arrest was cardiac in 33.8% of patients. Cardiac arrest was witnessed by the advanced life support (ALS) team in 15.6% of cases. Asystole was the most frequent initial rhythm at time of arrest (46.4%). The highest survival rate (P<0,001) was observed in cases with initial VF and pulseless VT, while patients with asystole and pulseless electrical activity (PEA) had the least chance of survival. Within the whole group of patients, ROSC was detected with a frequency of 69.7%. The frequency of patients who died in the field or during admission to hospital was 58.9%, while 28.6% of admitted patients died before discharge. Thirteen percent of patients survived until discharge, and the overall six-month and one-year survival rates were 11.3% and 10%, respectively. No statistical difference in survival rates among the cities was found
Conclusion. The Utstein template should be implemented in the form of an official protocol for out-of-hospital CPR follow-up in all emergency medical services in Serbia.


Key words: out-of-hospital CPR, outcome, follow-up, Utstein style, Serbia

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Rapid Sequence Intubation in the Pre-Hospital Setting – Difference Between Trauma and Nontrauma Patients


Aim. To determine, in a prospective observational study, whether there are differences in the practice of rapid sequence intubation (RSI) and to ascertain the characteristics between trauma and non-trauma patients that were intubated in a pre-hospital setting.
Methods. Included were patients (18 years and over) who were not in cardiac arrest and who underwent RSI and were transported to hospital. From January 2000 to December 2006 we intubated 636 patients in cardiac arrest, 159 critically ill non-trauma patients and 142 trauma patients. Placement of an endotracheal tube was confirmed by capnography. We compared medical and trauma groups of intubated patients. We used the two-independent sample t-test, Chi-square test and Wilcoxon-Mann Whitney test for statistical analysis.
Results. Statistical differences between groups (medical vs. trauma): initial main arterial pressure (104.9 +/- 34.6 vs. 90.7 +/- 24.8; p=0.01), blood glucose levels (9.2 +/- 3.5 vs. 5.9 +/- 1.9; p=0.011), administration of colloids (13,1 % vs. 70,2; p=0.003) and Hyperhaes (2.5 % vs.17.6 %; p=0.001), male gender (62.3 vs 81.6; p=0.014), rate of RSI (71.1 % vs. 96.4 %; p<0.001), initial GCS distribution 3-4/5-8/9-15 (30.9 % /61.6 % /7.5 % vs 11.7 % /60,2 % /28,1 %; p<0.001), initial pet CO2 (49,5 +/- 8,4 mmHg vs. 32,8 +/- 5.4 mmHg; p=0.007), APACHE II first day of hospitalization (25,9 +/- 4.9 vs. 20,8 +/- 3.6; p=0.002) and hospital mortality (78/159 (49.1 %) vs. 44/142 (30.1 %); p=0.023). We also analyzed the number of intubation attempts, intubation success rate, perceived difficulty of intubation and side effects with complications. The hospital survival analysis showed that survivors are younger (54.2 +/- 19.9 vs. 62.3 +/-18.8; p=0.019), have a higher rate of RSI (175/179(97.7 %) vs. 75/122(61.6 %); p=0.002) and have a better (lower) APACHE II score (19.9 +/-3.6 vs.28.3 +/- 4.6; p=0.002). We found the highest mortality rate in the subgroup of patients with non-traumatic intracranial hemorrhage (58.8 %, 60/102).
Conclusion. In non-trauma, critically ill patients we found a lower rate of RSI, more patients with an initial GCS of 3-4, higher APACHE II first day, higher initial pet CO2 and higher hospital mortality than in trauma patients.


Keywords: rapid sequence intubation, pre-hospital setting, injured patients, critically ill patients, prognosis

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