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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Thromboelastometry in neonates and infants undergoing cardiac surgery

Abstract

Introduction. Rotational thromboelastometry (ROTEM) in monitoring coagulation in children undergoing cardiac surgery has been studied with promising results. Since the data about ROTEM in infants and neonates undergoing cardiac surgery are scarce, the aim of our study was to asses ROTEM abnormalities in this patient group.

Methods. Infants and neonates undergoing cardiac surgery on cardiopulmonary bypass were included in this prospective, observational study conducted in a level III multidisciplinary neonatal and pediatric intensive care unit (ICU) between May 2011 and January 2012. ROTEM analysis, together with determination of platelet count, international normalized ratio of prothrombin time (INR), activated partial thromboplastin time (PTT), and fibrinogen concentration, was done in all neonates and infants before surgery (t1), after admission to ICU (t2) and 24 hours after surgery (t3).

Results. Twenty infants and neonates were operated on during the time of the study. ROTEM abnormalities seen after surgery (t2) were: thrombocytopenia 14, hypofibrinogenemia 1, mixed hypofibrinogenemia and coagulation factor deficiency 1, and mixed thrombocytopenia with mild hyperfibrinolysis 1. Three patients were found to have normal ROTEM results. The median values of all except one of the ROTEM tests, as well as platelet count, INR, PTT, and fibrinogen concentration, showed significant prolongation or deterioration after admission to ICU and these deteriorations persisted in several parameters for 24 hours.

Conclusions. In our neonates and infants, cardiac surgery on cardiopulmonary bypass predominantly affects platelets, although most of the ROTEM parameters deteriorated after admission to ICU.

Key words: thromboelastometry, cardiac surgery, neonate, infant, thrombocytopenia, hypofibrinogenemia.

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The significance of demographic factors (age, sex, preoperative physiological status) and type of surgery on patients’ outcome in ICU

Abstract

The incidence of postoperative death has changed little in recent years. Most deaths occur in older patients with coexisting medical diseases who undergo major surgery.

The objective of our research was to investigate the significance of demographic factors (age, gender, preoperational physiological status) and type of surgery on the outcome of treatment. This study included 288 patients older than 18 years of age that were treated in the intensive care unit (ICU) for at least 24 hours after a surgical procedure (both elective and emergency) between 1st January 2010 and 31st March 2011. The average age of patients included in the survey was 68 (range 19-88). APACHE II score was between 2.9 and 83.1 points, with an average value of 12.90 points. In this study, male gender (n=186) was much more common than female gender (n=102). Age of patients who died in the ICU was higher than the age of those who were discharged but it was not a statistically significant predictor of patient death. APACHE II score is associated with increased age of patients, neurosurgical operations and incidence of nosocomial infections. Patients’ age and female gender had a strong negative correlation with nosocomial infection. Actual mortality rate for patients was 21%. Ratio between actual and predicted mortality was 1.4.

Key words: demographics, ICU, APACHE, type of surgery, nosocomial infections.

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Correlation between mean platelet volume and total risk of cardiovascular disease

Abstract

Introduction. The association between mean platelet volume (MPV) and single cardiovascular disease (CVD) risk factors has previously been tested. The aim of our study was to evaluate the association between MPV and total risk of CVD.

Materials and Methods. In 216 consecutive outpatients referred for  a cardiology assessment because of multiple CVD risk factors, total CVD risk was estimated according to the Framingham Risk Score (FRS) as  low (<10%), intermediate (11-19%), and high (>20%). Additionally, FRS was adjusted for triglycerides (TG), body mass index (BMI) and a family history of CVD, important CVD risk factors which are not included in the FRS equation. Also, CVD risk was estimated according to terciles of MPV (<8.3, 8.3-9.1, >9.1 fL, respectively). Correlation between high sensitivity C-reactive protein (hs-CRP) and FRS was used as confirmation that our study hypothesis was properly set.

Results. MPV did not correlate with individual CVD risk factors or with FRS, either before, or after adjustment for additional CVD risk factors. Significant correlation between MPV and total CV risk was observed only in the adjusted high FRS group; namely, for persons in tercile 3, CVD risk was doubled (OR 2.2; 95% CI 1.05-4.64; P =0.038). In comparison, there was a strong linear correlation between hs-CRP and unadjusted (r=0.203, P=0.004) and adjusted (r=0.383, P<0.001) FRS.

Conclusion. Correlation between MPV and high total CVD risk suggests increased platelet activity primarily as a consequence and sign of atherosclerotic vascular damage. Linear correlation between hs-CRP with FRS confirms inflammation as an important mechanism of atherogenesis.

Key words: platelets, atherosclerosis, coronary risk prediction, Framingham risk score.

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Late manifestation of bilateral laryngeal nerve palsy after thyroidectomy

Abstract

Respiratory distress is a feared complication after thyroid surgery. Differential diagnosis includes bilateral recurrent laryngeal nerve palsy (BRLNP), local hematoma, vocal cord edema and laryngeal trauma. BRLNP results from intraoperative irritation without physical injury (neurapraxia), or intraoperative partial or complete transsection (axonotmesis and neurotmesis, respectively) of the recurrent laryngeal nerve (RLN). RLN palsy typically manifests immediately in the postoperative course. However, in rare cases there is a delayed, progressive development of BRLNP, potentially leading to respiratory failure in emergency setting weeks after initial surgery. Herein we report on a patient developing massive respiratory distress secondary to BRLNP 5 weeks after thyroidectomy for massive goiter. With the current tendency to decrease the length of hospital stay after thyroid surgery, late onset palsy of the RLN should be included into the differential diagnosis for acute respiratory distress in patients with recent history of thyroid surgery.

Key words: bilateral recurrent laryngeal nerve palsy, respiratory distress, thyroidectomy, goiter, postoperative complication.

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Long lasting neurocardiogenic reflex provoked by emotional trigger

Abstract

A 53-year-old man presented with a protracted presyncope and profound hypotension and bradycardia due to emotion related vasovagal reaction. Electrocardiogram obtained 20 minutes after the onset of presyncope revealed junctional rhythm at 38 beats per minute (bpm). After supination, clinical symptoms and hemodynamic disturbances immediately resolved. Careful cardiologic evaluation revealed significant stenosed coronary vessels. Maintaining the vertical position may be responsible for persistent bradycardia and hypotension after neurocardiogenic reflex provocation.

Key words: neurocardiogenic syncope, cardiovascular event.

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