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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

The effect of ambient noise in the NICU on cerebral oxygenation in preterm neonates on high flow oxygen therapy


In this early pilot study, we sought to determine if the alteration in these physiologic effects in premature infants in response to ambient noise in the NICU could be assessed evaluating cerebral blood saturation. Three premature infants, on high flow nasal cannula oxygen support (HFNC), at less than 34 weeks of gestation were included in the study. Three variables were used to evaluate sound levels due to AAP and EPA guidelines; Leq,1h, L10,1h and Lmax,1min.

All of the patients studied were found to be exposed to statistically significant noise levels (above recommendation) throughout all of the time periods measured. Noise levels were found to be similarly elevated during the 1 am and 3 pm time periods as well, though not as much as compared to the 7 am measure. A statistically significant difference was found within every patient’s rSO2 levels in both hemispheres, but also in the absolute differences of rSO2. Positive significant statistical correlations were found between the average rSO2 and Leq,1h (ρ=0.14), Lmax,1min (ρ=0.18), L10,1h (ρ=0.15). Significant negative correlations were found between the absolute difference levels and Lmax,1min (ρ=-0.3), and L10,1h (ρ=-0.18)

This data highlights the need for further study as to the potential impact of noise on the cerebral physiology of premature infants. Further research is needed to assess the potential long-term side effects of environmental noise on the premature infant’s brain.

Key words: noise, infant, new-born, neonatology, noise measurement

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Methemoglobinemia caused by accidental poisoning by nitric oxide – case report


The aim of this paper is to present a case of methemoglobinemia induced by accidental poisoning by nitric oxide, in a male infant at the age of 3 months and 4 days. Methemoglobinemia is a disease in which the hemoglobin is in the oxidized form and can not bind oxygen, and becomes manifested when erythrocytes contain more than 1% of methemoglobin. This condition can be idiopatic or acquired, and requires sub-specialist diagnostic evaluation and treatment.

Key words: methemoglobinemia, nitric oxide, infant

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Biomarkers of sepsis in neonates and children


Sepsis, and related complications, is still a common cause of death in hospitalized patients worldwide, especially in critically ill neonates and children. Sepsis is also responsible for significant morbidity, and financial burden. It is very important to recognize sepsis early, since delayed diagnosis is associated with worse outcome. The early detection of sepsis remains a great challenge for clinicians because the use of blood cultures, the gold standard for diagnosis of bacteremia, is fraught with difficulties. The role of different immune and metabolic biomarkers is to improve the diagnosis, treatment and prognosis of sepsis. White blood cell count, C-reactive protein and procalcitonin are currently the most widely used biomarkers, but they have limited abilities to distinguish sepsis from other inflammatory conditions or to predict outcome. In this review, these biomarkers will be discussed along with novel diagnostic, prognostic and treatment response biomarkers, including interleukins -6, -8, -18, tumor necrosis factor – alpha, CD11b, CD64 and CD15s. The future of sepsis biomarkers lies in extensive validation studies of all novel biomarkers and their combinations as early predictors of sepsis. Also, research to identify novel sepsis biomarkers and develop specific therapeutic strategies based on biomarker information has to be continued.

Key words: infant, child, biomarkers, CD15s antigen, C-reactive protein, procalcitonin

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Thromboelastometry in neonates and infants undergoing cardiac surgery


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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Successful right atrial thrombus lysis with alteplase in a nine month old infant


Objective. To present the case of an infant with a catheter related atrial thrombus resolved with local instillation of alteplase.
Clinical presentation. Echocardiography (ECHO) was performed in an infant with sepsis to estimate cardiac contractility, and a large mobile thrombus (28 x 8 mm) was detected in the right atrium. A left subclavian, double lumen, central venous line (CVL, 4 French, 8 cm), inserted 10 weeks previously, was left in place. Standard treatment with enoxaparine was commenced twice daily for 10 days at a dose of 1 mg/kg. Repeat ECHO showed no changes in thrombus size or mobility. Therefore, alteplase was administered into the distal catheter (1 mg in normal saline) at a dose of 110% of its priming volume. The dwelling time was 2 hours. Since no changes in thrombus size were observed, the same dose was given into the proximal catheter. ECHO performed 24 hours later showed a significant reduction in thrombus size. The third dose of alteplase was administered into the proximal catheter. ECHO showed complete dissolution of the right atrial thrombus. No bleeding was observed during and following therapy, and there were no signs of hemodynamic instability. The CVL was safely removed the same day and no endoluminal thrombus was seen.
Conclusion. Local instillation of alteplase in three doses was a safe and effective approach to the management of a large catheter-related intraatrial thrombus. Systemic thrombolytic therapy, associated with an increased risk of bleeding, and open heart surgery were avoided.

Key words: right atrial thrombus, alteplase, fibrinolysis, central venous line, infant

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