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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

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Vasoactive-inotropic score as a predictor of in-hospital mortality in out-of-hospital cardiac arrest


Background: The Vasoactive-Inotropic Score (VIS) is an objective clinical tool used to quantify the need for cardiovascular support in children and adolescents after surgery and to predict prognosis of pediatric septic shock. Considering the post-cardiac arrest syndrome (PCAS) is a sepsis-like syndrome, we aimed to investigate the correlation between VIS and in-hospital mortality in out-of-hospital cardiac arrest (OHCA) patients who achieved a sustained return of spontaneous circulation (ROSC) and admitted to the intensive care unit (ICU).

Methods: A retrospective chart review of 504 OHCA patients who were admitted to the emergency room with OHCA from Jan 2015 to Dec 2016 was done. VIS was calculated with the recorded administration rate of the drugs on electronic medical record at the same time during the first 24 hours in ICU. The highest value of VIS in 24 hours (24hr-peak VIS) was used for investigating the correlation between VIS and in-hospital mortality.

Results: Among 504 OHCA patients, 166 patients were admitted to the intensive care unit and 116 patients died during hospital stay. The probability of in-hospital mortality was significantly higher when 24hr-peak VIS was higher than 33.3 [Odds ratio (OR) = 3.18, 95% CI = 1.22 – 8.29, p value = 0.018].

Conclusion: 24hr-Peak VIS could be a good scoring system for predicting in-hospital mortality in OHCA patients who admitted to ICU. The AUC was 0.762 (95% CI = 0.690 to 0.825) and the optimal cut-off values were 33.3 (sensitivity 0.764, specificity 0.610).

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Fluid optimisation in pancreas surgery


Background. Optimal intravascular blood volume, cardiac output and sufficient oxygen supply is a mainstay in major abdominal surgery. Adequate haemodynamic management can improve a favourable outcome and shorten the duration of hospital stay.

Our study anticipated different fluid and vasoactive drug consumption and less complications during the pancreatic surgery in the group of patients where extended haemodynamic monitoring was applied.

Materials and methods. 59 adult patients, ASA 2-3, undergoing elective pancreas surgery, were included in the study. In 29 patients in the study group (SG – extended haemodynamic monitoring), cardiac index (CI), mean arterial pressure (MAP) and nominal stroke index (SI) were maintained within 80% of baseline values with actions following study protocol. Patients’ groups were homogenous, even when divided into 4 subgroups (control group (CG) and without epidural catheter (EC), CG and with EC, SG and without EC, SG and with EC).

Intraoperative variables (amount of fluids, vasopressors, surgery duration) and hospitalisation duration, wound healing, reoperation, mortality and other complication were recorded on the postoperative days 3, 5, 8, 15 and on hospital discharge.

Results. There was no difference in ASA health status, intraoperative management and duration of hospitalisation in 4 subgroups. There is a significant difference in intraoperative use of vasopressor support between 4 subgroups (Fisher exact test, p=0,032). All patients in SG with EC required vasopressors. Number of patients with major complications were not statistically different between groups. Pulmonary embolism, postoperative food intolerance and myocardial infarction have occurred only in CG.

Conclusion. In our study there was no difference in overall fluid and vasoactive drug demand. Although in the studied subgroup of patients with additional epidural anaesthesia there was significantly increased demand for vasoactive drugs. The incidence of complication was low in both groups, however, some of major complications occurred only in CG.

Keywords: haemodynamic monitoring, fluid optimisation, postoperative outcome, pancreatic surgery

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Rocuronium versus succinylcholine for rapid sequence intubation in patients with bowel obstruction


Introduction. The aim of the study was to determine intubation conditions in the patients receiving rocuronium in comparison to succinylcholine for rapid sequence intubation during the induction of anesthesia for operative management of bowel obstruction.

Methods. In the randomized controlled study 30 adult patients with bowel obstruction undergoing urgent surgery were randomly allocated in two groups. For muscle relaxation the S-group of patients received succinylcholine (1.5 mg/kg) and the R-group rocuronium (1.2 mg/kg). Intubation conditions were evaluated using a grading system according to Viby-Morgenson. Primary outcomes were intubation conditions 1 minute after the application of a muscle relaxant. Secondary outcome measures were heart rate, blood pressure, and pulse oximetry; potassium and myoglobin serum level.

Results. All patients were orotracheally intubated in the first attempt. During induction, we didn’t observe vomiting or aspiration. Overall intubation conditions in the S-group were statistically significantly better than in the R-group. After RSI there was a statistically significant decrease in systolic and diastolic blood pressure in both groups and statistically significant decrease in heart rate in the S-group. After RSI the potassium level in the S-group was significantly higher in comparison to the R-group and serum myoglobin level non-significantly increased in the S-group and statistically significantly decreased in the R-group.

Conclusion. The results show that rocuronium in RSI patients with bowel obstruction enables the same intubation conditions as succinylcholine and the same risk of aspiration which allows succinylcholine replacement and avoidance of its side effects.

Key words: Rocuronium, succinylcholine, rapid sequence intubation, bowel obstruction, intubation conditions

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Neutrophil/lymphocyte ratio and Red blood cell distribution width are independent risk factors for 30-day mortality in Gastrointestinal system bleeding patients


Background. In this study, we aimed to examine demographic and endoscopic features of patients with GI bleeding to determine the factors affecting 30-day mortality.
Method. Patient’s demographic features, laboratory outcomes, comorbidities, drug use, endoscopy outcomes, Glasgow-Blatchford scores, and mortality status were examined. The factors affecting 30-day mortality were investigated.
Results. The mean age of the patients was 58.2±17.4 years, and 72.1% were male patients. 30-day mortality rate was found to be 14.4%. The mean age of patients who died was high (p<0.05). The incidence of mortality was high in the presence of comorbidity, malignancy, and cirrhosis (p<0.05). Systolic blood pressure was low in the patients who died (p<0.05). No significant correlation was found between mortality and gender, symptoms, predisposing factors, lesion type and Forrest score, diastolic blood pressure and heart rate (p>0.05). Urea, neutrophils, red blood cell distribution width / platelet ratio, neutrophil / lymphocyte ratio and RDW levels were high, and hemoglobin level was significantly low in patients with a mortal progression (p<0.05). No significant correlation was found between mortality, and platelet and lymphocyte levels (p>0.05). Glasgow-Blatchford score was significantly higher in patients who died (p<0.05).
Conclusion. Many factors affect 30-day mortality in GI bleeding. It should be remembered that follow-up of patients with an advanced age who have comorbidity and impaired hemodynamics should be kept for long, and that these patients are at a high risk for mortality.
According to our results, NLR and RDW are independent factors that determine the 30-day mortality in upper GI bleeding.

Keywords: emergency, mortality, NLR, RDW

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Misleading presentation of ruptured abdominal aortic aneurysm and the role of point-of-care ultrasound for diagnosis


If not recognized and treated early enough, the rupture of abdominal aortic aneurysm (rAAA) embodies a devastating medical emergency. It is associated with high morbidity and mortality which can reach up to 100 % in untreated individuals. Patients are usually hypotensive, shocked, complain of pain in the abdomen or back, and can have a palpable pulsatile abdominal mass. rAAA can be misdiagnosed due to patient’s comorbidities, site of rupture, or unusual presentations. Unusual clinical presentations include transient lower limb paralysis, right hypochondrial pain, groin pain, testicular pain, iliofemoral venous thrombosis, and others. When ruptured abdominal aneurysm is suspected an emergency ultrasound should be performed. In this article we are going to present a patient with unusual presentation of ruptured abdominal aneurysm and the importance of point-of-care ultrasound in similar cases.

Key words: abdominal aortic aneurysm, rupture, point-of-care ultrasound

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