ABSTRACT
Introduction: Blood lactate is a marker of tissue hypoxia while capillary refill time (CRT) is a surrogate of tissue perfusion. Measuring these parameters is recommended for assessing circulatory status and guiding resuscitation. However, blood lactate is not widely available in African emergency departments. Additionally, CRT assessment faces challenges related to its precision and reproducibility. This study aims to evaluate the accuracy of visual CRT(V-CRT) compared to plethysmographic CRT (P-CRT) in predicting lactate levels among septic patients. Methods: This prospective observational study enrolled consecutive patients with sepsis or septic shock over a 6-month period from a tertiary hospital in Marrakech, Morroco. V-CRT and P-CRT were evaluated upon admission, and simultaneous measurements of arterial lactate levels were obtained. The precision of V-CRT and P-CRT in predicting arterial lactate was assessed using ROC curve analysis. Results: Forty-three patients aged of 64±15 years, of whom 70 % were male, were included in the study. Of these, 23 patients (53 %) had sepsis, and 20 patients (47 %) experienced septic shock. Both V-CRT and P-CRT demonstrated statistically significant correlations with arterial lactate, with correlation coefficients of 0.529 (p < 0.0001) and 0.517 (p = 0.001), respectively. ROC curve analysis revealed that V-CRT exhibited satisfactory accuracy in predicting arterial lactate levels >2 mmol/l, with an area under the curve (AUC) of 0.8 (95 % CI=0.65 - 0.93; p < 0.0001). The prediction ability of P-CRT was lower than V-CRT with an AUC of 0.73 (95 % CI: 0.57-0.89; p = 0.043). The optimal thresholds were determined as 3.4 s for V-CRT (sensitivity = 90 %, specificity = 58 %) and 4.1 s for P-CRT (sensitivity = 85 %, specificity = 62 %). Conclusion: These findings suggest that the plethysmographic evaluation did not improve the accuracy of CRT for predicting lactate level. However, V-CRT may still serve as a viable surrogate for lactate in septic patients in low-income settings.
ABSTRACT
Introduction: Snakebites are a leading cause of mortality and permanent disabilities especially among children in tropical countries and rural areas such as Morocco. Thus, a nationwide management protocol including specific antivenom therapy along with prevention strategies was implemented to reduce the overall snakebites morbimortality. Patients and methods: Our retrospective study aimed to describe the clinical aspects of snakebite envenomation before and after the implementation of this protocol in children admitted to the pediatric intensive care unit (PICU) in Marrakesh-Morocco for a period of 11 years. Results: A total of 75 cases were included and were mostly male (70%) with a mean age of 10 years old. Most envenomations were mild or severe (75%) and often occurred during outdoor activities in limb extremities. Altered hemostasis frequently occurred in 67% of cases but was rarely associated with severe exteriorized hemorrhage. Moderate anemia and PNN- predominant leukocytosis were often observed at admission (52.2% and 58%) but quickly tended to normalize before 48 h. Local symptoms were the main dread as they quickly evolve to a compartment syndrome and necrosis in the absence of antivenom therapy. Fasciotomy was performed in 33% of cases while 5 children required limb amputation. Antivenom administration (n = 39) was statistically significant for rapid improvement in hemostasis disorders, reduced blood transfusions and fasciotomy for compartment syndrome as well as a shortened length of stay in PICU. The onset of acute kidney injury was observed in 18 cases but restored in most patients within 48 h (77%). Five children died of which only two had received delayed antivenom immunotherapy due to its unavailability and deferred hospital admission. Conclusion: The advent of specific serotherapy has made it possible to optimize the management of patients and to prevent and treat local and systemic complications thus improving the overall prognosis; nevertheless, primary prevention remains the key to reducing snakebites morbimortality.