Role of Bedside Ultrasonography in Assessment of Diaphragm Function as a Predictor of Success of Weaning in Mechanically Ventilated Patients / 결핵및호흡기질환

Background@#Weaning failure is common in mechanically ventilated patients, and if ultrasound can predict weaning outcome remains controversial. The purpose of this study was to evaluate the diaphragmatic function (thickness and excursion) measured by ultrasound as a predictor of the extubation outcome. @*Methods@#We included 62 mechanically ventilated patients from the chest intensive care unit in this study. Sixty-two patients who successfully passed the spontaneous breathing trial (SBT) were enrolled. The transthoracic ultrasound of the diaphragm was performed during an SBT to the assess diaphragmatic function (excursion and thickness), and they were classified into the successful extubation group and the failed extubation group. @*Results@#There was a statistically significant increase in the successful extubation group in the diaphragmatic excursion and thickness fraction (p<0.001), a statistically significant negative correlation between the diaphragmatic function and the duration of the mechanical ventilation, and a statistically significant negative correlation between the diaphragmatic excursion and the Acute Physiology and Chronic Health Evaluation II. The diaphragmatic excursion cutoff value predictive of weaning was 1.25 cm, with a specificity of 82.1% and a sensitivity of 97.1% respectively, and the diaphragmatic thickness cut-off value predictive of weaning was 21.5%, with a specificity of 60.7% and a sensitivity of 91.2%, respectively. @*Conclusion@#The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

The Association between Neonatal Sepsis and C-reactive Protein: A Cross-Sectional Study at Tertiary Care Hospital

Background: Neonatal Sepsis is a blood bacterial infection that develops in neonates and it is considered as a serious and life-threatening disease. The aim of this study was to evaluate the diagnostic value (sensitivity and specificity) of CRP in the diagnosis of neonatal sepsis. Methods: A cross-sectional hospital-based study was carried out at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia between 2016 and 2017. In this study, we included all neonates who have been diagnosed with neonatal sepsis during the study period. Based on the result of blood culture we divided our study population into confirmed neonatal sepsis cases and neonates with clinical manifestation of sepsis and negative blood culture results. Results: A total of 145 neonates were included, 51 were selected in the control group (normal neonates without any signs of sepsis), 46 neonates had sepsis with a positive blood culture and 48 neonates in clinical sepsis group (with clinical signs of sepsis but their blood culture was negative). The CRP level was significantly high in neonates in the sepsis group (with a mean=7.02 ng/ml) compared with neonates in the clinical sepsis group (mean=3.73 ng/ml) and in the control group (mean=0.4 ng/ml). The frequency of the respiratory problems and jaundice was higher among neonates in the sepsis group compared to clinical sepsis group (p<0.01). CRP has a high sensitivity (95%) and specificity (86%) at the cut-off point of 4.09 ng/ml. Conclusion: CRP has been found to each high level in neonatal sepsis and it has a relatively high diagnostic value when 4.09 ng/ml is used as a cutoff point for the diagnosis of the neonatal sepsis.

Uso de ecocardiografia junto ao leito para medir índices cardíaco e de resistência vascular sistêmica em pacientes pediátricos com choque séptico / The use of bedside echocardiography for measuring cardiac index and systemic vascular resistance in pediatric patients with septic shock

RESUMO Objetivo: Acompanhar o índice cardíaco e o índice de resistência vascular sistêmica até a ressuscitação. Métodos: Por meio de ecocardiografia junto ao leito, obteve-se um conjunto de parâmetros hemodinâmicos, inclusive débito cardíaco, volume sistólico, índice cardíaco, índice de resistência vascular sistêmica, integral velocidade-tempo, índice de desempenho miocárdico, tempo de reenchimento capilar e frequência cardíaca no momento zero após infusão de fluidos em bolo, e início e utilização de fármacos inotrópicos, com seguimento até 6 horas e 24 horas. Resultados: Incluíram-se 45 pacientes com choque séptico adquirido na comunidade. Os focos de infecção foram gastrenterite (24%), perfuração intestinal com necessidade de cirurgia emergencial (24%), pneumonia (20%), infecção do sistema nervoso central (22%) e infecção de tecidos moles (8%). Os isolados mais frequentes foram de Klebsiella e Enterobacter. Estimamos os fatores que afetaram o índice cardíaco: pressão venosa central elevada no momento zero (r = 0,33; p = 0,024) e persistência de frequência cardíaca elevada após 6 horas (r = 0,33; p = 0,03). O índice de resistência vascular sistêmica foi alto na maioria dos pacientes no momento zero e após 24 horas, e por ocasião da ressuscitação, afetando inversamente o índice cardíaco, assim como a integral velocidade-tempo (r = -0,416; -0,61; 0,55 e -0,295). O tempo de reenchimento capilar aumentado foi preditor clínico de valores baixos de integral velocidade-tempo após 24 horas (r = -0,4). O índice de mortalidade foi de 27%. Nos pacientes que não sobreviveram, observaram-se índices de resistência vascular sistêmica mais baixos e débitos cardíacos mais altos. Conclusão: O índice de resistência vascular sistêmica esteve persistentemente elevado em pacientes com choque frio, o que influenciou no índice de volume sistólico, no índice cardíaco e na integral velocidade-tempo. O uso de ecocardiografia para obtenção de mensurações hemodinâmicas é importante em pacientes pediátricos com choque séptico, para que se possam ajustar as doses de vasodilatadores e vasopressores, e obter os objetivos da ressuscitação em tempo apropriado.

ABSTRACT Objective: Follow-up of cardiac index and systemic vascular resistance index by bedside echocardiography until resuscitation. Methods: A set of hemodynamic parameters was obtained, including cardiac output, stroke volume, cardiac index, systemic vascular resistance index, velocity time integral, myocardial performance index, capillary refill time, and heart rate at 0 hours after fluid boluses before the start of inotropes, and followed up after 6 hours and 24 hours. Results: Included were 45 patients with community-acquired septic shock. Septic foci were gastroenteritis (24%), intestinal perforation requiring emergency surgery (24%), pneumonia (20%), central nervous system infection (22%) and soft tissue infection (8%). Klebsiella and Enterobacter were the most frequent isolates. We estimated the factors affecting the cardiac index: high central venous pressure at zero time (r = 0.33, p = 0.024) and persistently high heart rate at hour 6 (r = 0.33, p = 0.03). The systemic vascular resistance index was high in most patients at 0 and 24 hours and at the time of resuscitation and inversely affected the cardiac index as well as affecting the velocity time integral (r = -0.416, -0.61, 0.55 and -0.295). Prolonged capillary refill time was a clinical predictor of the low velocity time integral at 24 hours (r = -0.4). The mortality was 27%. Lower systemic vascular resistance index and higher cardiac output were observed in nonsurviving patients. Conclusion: There was a persistently high systemic vascular resistance index in cold shock patients that influenced the stroke volume index, cardiac index, and velocity time integral. The use of echocardiograms for hemodynamic measurements is important in pediatric septic shock patients to adjust dilators, and vasopressor doses and achieve resuscitation targets in a timely manner.

Effects of red blood cell transfusions on acid base balance, glucose and electrolytes in preterm infants

Preterm neonates comprise the most heavily transfused group of patients, and about 85% of extremely low birth weight newborns receive a transfusion by the end of their hospital stay. The aim of this study was to assess the possible metabolic effects of RBC transfusion on preterm infants especially during the first 2 weeks of life, and its relation to blood volume. This study was conducted on 40 preterm neonates with gestational age of less than or equal to 34 weeks. They received RBCs transfusion during first 2 weeks of life. Venous blood samples of infants were collected 2 to 4 hours before and 1 hour after the end of transfusion to evaluate hemoglobin [Hb] level, hematocrit, acid-base, electrolytes, and glucose status. Then infants were classified into two main groups: those who received RBCs volume less than or 20 ml/kg and those who received RBCs volume more than 20 ml/kg. Infants received a mean volume of 20.38 +/- 3.2 ml per kg RBCs [range 10.9 -26.6 ml/kg] at a median age of 9.8 +/- 3.6 days. After transfusion, a significant increase of mean Hb [p<0.001], mean Hct [p<0.001], pH [p<0.001], pO2 [p<0.05] and a significant decrease of the pCO2 [41.46 +/- 8.8torr vs. 35.4 +/- 9.34torr; p<0.001] were observed. In addition, there was a significant increase of serum K[+] [p<0.001], and a significant decrease of Ca[+2] [p<0.001].A positive correlation was found between the K[+] intake and the changes of kalemia [r=0.99; p=0-00]. Furthermore we observed an inverse correlation between the patients calcium intake and the changes of calcemia [r=-0.35; p=0.02]. On comparing the changes in clinical and biochemical variables between two groups after transfusion, we observed a significant increase in mean Hb and Hct associated with a significant decrease in mean serum Ca[+2] [p<0.001] in the group receiving the larger blood volume. RBCs transfusion was effective in improving anemia, oxygenation, increasing pH and decreasing CO2 and Ca[+2]. However, from a more clinically relevant point of view we demonstrated the development of hyperkalemia, especially in infants with a previously borderline hyperkalemia