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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Invasive Candida infections in the nursery: state of the art


Neonatal sepsis caused by fungi (mainly Candida spp.) causes a huge burden of morbidity and mortality, poor late outcomes, as well as increased hospital costs.

Invasive Candida Infections (ICI) include bloodstream, urine, cerebrospinal, peritoneal infections, infections starting from burns and wounds, or from any other usually sterile site.

Premature neonates are particularly prone to this kind of disease, due to their decreased innate and adaptive immunities, translating into a specific, decreased resistance to candidiasis.

This specific, increased risk for ICI is greatest when gestational age and birth weight are lowest. As the burden of ICI has been increasing over the last years, research efforts have been focused towards identifying key risk factors, effective preventative strategies, and efficacious and well-tolerated antifungal drugs for the neonatal population.

This article summarizes the most remarkable issues in these areas, and features an overview of the current diagnostic, preventative and treatment strategies.

Key words: Candida, neonate, infection, preterm, micafungin, fluconazole

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Hyperperfusion and intracranial haemorrhage after carotid angioplasty with stenting – latest review


The number of endovascular procedures is constantly increasing. As far as the carotid artery is concerned, carotid angioplasty with stenting (CAS) is an alternative to surgical treatment (carotid endarterectomy; CEA).

Two major devastating complications can occur after both procedures – cerebral hyperperfusion syndrome (CHS) and intracranial haemorrhage (ICH).

The incidence of CHS and ICH in CAS is fortunately low but overall morbidity and mortality remains high.

This latest review re-evaluates the pathogenesis, clinical features, risk factors and diagnostic procedures as well as management of these two complications.

Key words: carotid artery stenting, complications, hyperperfusion syndrome, intracranial haemorrhage

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Near infrared spectroscopy tissue oxygenation in infants with bronchiolitis during mechanical ventilation and spontaneous breathing


Introduction. Near-infrared spectroscopy (NIRS) was used in infants with acute bronchiolitis as a noninvasive indicator of tissue oxygenation to determine regional tissue oxygen saturation (rStO2) and fractional tissue oxygen extraction (FTOE) during mechanical ventilation and spontaneous breathing.

Methods. Twenty-seven infants with bronchiolitis that needed mechanical ventilation were included in a prospective study. Regional StO2 in brain, liver, kidney and skeletal muscle tissue was measured on admission to the Intensive Care Unit (ICU), on day 1 (D1); after two to three days of mechanical ventilation (D2); on the last day of mechanical ventilation (D3) and during spontaneous breathing (D4). Measurements were conducted by in-vivo optical spectroscopy. For research purposes we divided the infants according to C-reactive protein (CRP) levels, with a cut-off value of 10 mg/ml on admission, into low (l-CRP) and high (h-CRP) groups.

Results. During mechanical and spontaneous breathing we found lower StO2 and higher FTOE for skeletal muscle at D4 compared to D1-D2 in the h-CRP group of patients. Differences between l- and h-CRP groups in rStO2 were found for brain tissue on D3, D4, and in rStO2 and FTOE for liver tissue on D3. A strong negative correlation was found between rStO2 and FTOE in all tissues. A positive correlation was found between CRP and rStO2 and negative between CRP and FTOE in skeletal muscle among all patients combined.

Conclusion. Only Infants with acute bronchiolitis in the h-CRP group have significant changes in rStO2 and FTOE in skeletal muscles during mechanical ventilation and spontaneous breathing. Regional StO2 and FTOE in all the other measured tissues never decreased below normal values.

Key words: bronchiolitis, near-infrared spectroscopy, fractional tissue oxygen extraction (FTOE), regional oxygen saturation (rStO2)

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CPR quality reduced due to physical fatigue after a water rescue in a swimming pool


Objective. This study aimed to analyse the influence of physical fatigue, resulting from a simulated aquatic rescue, at a swimming pool, on the quality of cardiopulmonary resuscitation (CPR) delivered by the rescuer.

Design, setting and participants. An intragroup design with 27 lifeguards was used in this study. The quality of CPR delivery was evaluated for two minutes for all subjects while they were at rest (test 1), as well as after a simulated aquatic rescue at a swimming pool (test 2). A Resusci Anne® SkillReporter™ (Laerdal Medical Limited, Norway) manikin was used to retrieve reports on CPR delivery, compliant with the most recent international guidelines (30:2, chest compression: ventilation ratio).

Results. Rescue-related physical fatigue had a significant influence on the total number of chest compressions as well as on the ratio of correct chest compressions. Physical fatigue triggered by a swimming pool water rescue negatively influenced CPR delivery quality. These results show that the detrimental effects of physical fatigue on CPR delivery remain important, even in a swimming pool environment.

Conclusions. Training programs should reflect this finding, and focus on enabling lifeguards to deliver proper CPR, even while exhausted and for long periods of time.

Key words: emergency medicine, drowning, resuscitation

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Premedication with midazolam is equally effective via the sublingual and intravenous route of administration


Background. The aim of this study was to investigate the clinical efficacy and potential side effects of sublingual midazolam, used for premedication, in comparison with intravenous midazolam. The second aim was to explore cost-effectiveness of sublingual midazolam administration.

Methods. A prospective, randomized, controlled, single-blinded trial was conducted at the Clinical Hospital Centre Osijek, Croatia, during the period 1st of May till 31st of October, 2012. We enrolled 140 patients (American Society of Anesthesiologists (ASA) physical status I-II, age≥18 years) scheduled for some kind of elective surgical procedure. Exclusion criteria were ASA III or higher, psychiatric disorders, allergy to midazolam and use of psychotropic drugs. Patients were randomized into one of two groups. One group received 2.5 mg of midazolam intravenously and the other group received 1/4 of a midazolam tablet (approximately 3.75 mg) sublingually. Sedation was clinically evaluated using the Ramsey sedation scale at 0, 10, 20 and 30 minutes after drug administration. We also noted side effects and degree of amnesia.

Results. Ten minutes after administration of premedication, a significantly higher number of patients in the intravenous group had a Ramsey score of 2 (p=0.000). Ten and twenty minutes after drug administration, most of the patients in the sublingual group had a Ramsey score 1-2, and after 30 minutes most of them had a Ramsey score 2-3, which is comparable with the intravenous (p=0.642) group.

Conclusion. Sublingual application of midazolam has an equivalent sedative effect as intravenous midazolam 20 minutes after administration but is associated with a bitter taste and weaker amnestic effect.

Key words: premedication, midazolam, sublingual, intravenous

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