Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation.

OBJECTIVE: In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile. METHODS: Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded. RESULTS: A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002). CONCLUSION: It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better. CLINICAL TRIAL REGISTRATION NUMBER: NCT05343702.

Thiol/Disulfide Homeostasis and Ischemia-Modified Albumin Levels in 61 Patients with Hypercapnia: A Case-Control Study.

BACKGROUND Hypercapnia is abnormally high arterial partial pressure of carbon dioxide (CO2). CO2 can affect redox signaling mechanisms, leading to production of oxidative derivatives. Thiol is formed by attaching a sulfhydryl group to a carbon atom. Under oxidative stress, it forms covalent bonds called thiol disulphide bonds. Serum albumin is modified to ischemia-modified albumin (IMA) by exposure to free radicals. This case-control study aimed to evaluate thiol/disulphide homeostasis and IMA levels in 61 patients with hypercapnia. MATERIAL AND METHODS We studied 61 patients with hypercapnia and 61 normocapnic volunteers in the control group, between May 2018 and January 2019; 56 of these patients were diagnosed with chronic obstructive pulmonary disease and 5 of them were diagnosed with obstructive sleep apnea syndrome. Arterial blood samples analyzed by using the Ellman reagent for thiol/disulphide data. A colorometric assay was used for detection of IMA levels. RESULTS Native thiol and total thiol values in the hypercapnic group were significantly lower than in the control group (P=0.024, P=0.006 respectively), as IMA values were significantly higher (P<0.001). There was no statistically significant difference between the hypercapnic and control groups in terms of disulphide, disulphide/native thiol, disulphide/total thiol, and native thiol/total thiol values (P>0.05). CONCLUSIONS In hypercapnic patients, there are changes in thiol/disulphide homeostasis and IMA levels. All significant differences in this study support that changes in thiol disulphide homeostasis and IMA in hypercapnic patients are indicators of oxidative stress.

Are thiol-disulfide homeostasis & neutrophil-to-lymphocyte ratio useful in the differential diagnosis of acute familial Mediterranean fever attacks & acute appendicitis?

Background & objectives: Continuous subclinical inflammation can be seen in patients with familial Mediterranean fever (FMF) during the attack-free period. The importance of oxidative stress parameters in acute appendicitis (AA) progression has also been shown in previous studies. So, oxidative stress and the oxidant/antioxidant balance may play a role in this persistent subclinical inflammation. With this background the main objective of this study was to investigate the usefulness of combining the thiol-disulfide homeostasis parameters and the neutrophil-to-lymphocyte ratio (NLR) in the differential diagnosis of AA and an acute FMF attack. Methods: The present study was conducted prospectively with 84 patients who were admitted to the emergency department between May 1, and December 31, 2018. Another 40 healthy individuals were assigned as the control group. The homeostasis parameters of thiol-disulfide were measured by a spectrophotometric method and NLR was measured in the patient and control groups. Results: Native thiol and total thiol values were lower, while disulfide values were insignificantly higher in patients with AA than in patients with FMF. The white blood cell (WBC), neutrophil and NLR values were significantly higher in the AA group (P<0.001, P<0.001, P<0.001, respectively). When the neutrophil cut-off value for AA was set at 8.55, the calculated sensitivity was 80 per cent, the specificity was 72.2 per cent, and the area under the curve was 0.837. Interpretation & conclusions: The results of this study suggest that neutrophil, WBC and NLR values can be useful in the differentiation of AA from an acute FMF attack.

Effectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial.

OBJECTIVE: Radial arterial puncture is a painful procedure. The aim of this study was to evaluate the effect of lidocaine spray (10%) on pain associated with radial artery blood withdrawal for arterial blood gas analysis. METHODS: This randomized, controlled, double-blind study was performed between December 2018 and September 2019. Before radial arterial puncture, 10% lidocaine or placebo spray was applied to each patient by the attending physician, who was blinded with regard to random assignment. The spray was administered six times on the site from a distance of 5 cm. After waiting for 5 min, a radial arterial puncture was performed routinely. The pain levels of patients during radial arterial puncture and 5 min after puncture were evaluated with the visual analog scale (VAS). The Wilcoxon test was used to compare pain scores during puncture. RESULTS: The research was performed with 67 patients (34 patients in the lidocaine group, 33 patients in the placebo group) who were admitted to the emergency department and required ABG analysis. Forty-three patients were men, and 24 were women. The ages of the patients ranged between 19 and 86 years, and the mean (± standard deviation) age was 56.3 ± 16.6 years. Pain levels, as measured by VAS, were significantly lower in the lidocaine group (24.00 mm IQR:[14.75-33.75]) compared with the placebo group (33.00 mm IQR:[22.00-61.50]) during radial arterial puncture (p = 0.011). CONCLUSIONS: The level of pain perceived during radial arterial puncture was significantly lower in those who were administered lidocaine spray. Lidocaine spray application can be used in pain management related to radial arterial puncture.

Assessment of the number of admissions for road traffic collisions and severity of injury in daylight saving time and permanent daylight saving time periods.

BACKGROUND/AIM: Permanent daylight saving time has been implemented in Turkey since 2016. The present study determines the characteristics of road traffic collisions in the short-term, trauma severity, and whether permanent daylight saving time has an impact on these parameters. MATERIALS AND METHODS: Drivers admitted because of road traffic collisions to a tertiary care university hospital emergency service two weeks before and after the transition to wintertime in 2014 and 2015 and summertime in 2015 and 2016 as well as those admitted two weeks before and after the same period with permanent daylight saving time in 2016 and 2017 wintertime and 2017 and 2018 summertime were included in the study. Trauma severity was measured using the Injury Severity Score. RESULTS: The study analysed the data of 710 patients. There was no statistically significant difference was found between admissions in the summertime and permanent daylight saving time periods in terms of gender, time of admission, week of admission, Injury Severity Score and outcome (P > .05 for all values). CONCLUSIONS: In this study, we examined the short-term effects of daylight saving time on road traffic collisions, and demonstrated that it had no impact on the number or time of admission, trauma severity and patient outcomes. More comprehensive studies covering longer periods can be performed across the country.

Transport of awake hypoxemic probable COVID 19 patients in the prone position.

OBJECTIVE: We aimed to investigate the effects of transport with prone position on hypoxemia in hypoxemic and awake probable COVID 19 pneumonia patients. METHODS: Hypoxic and awake patients with probable COVID 19 pneumonia who were referred to the Ankara City Hospital Emergency Department from 1 April to 31 May 2020 were included in this prospective study. Patients were transported in prone position and fixed on the stretcher. During the transport, patients continued receiving 2 l per minute oxygen with nasal cannula. Arterial blood gases were obtained from the patients before and after transport. The transport time was recorded as minutes. The primary outcome of the study is the increase of partial oxygen value in the arterial blood gas of patients after transport. RESULTS: It was found that pO2 and SpO2 end values were statistically significantly higher in the patient group compared to the initial values. In the group with transport duration of more than 15 min, a difference was found between the initial and end values in pO2 and SpO2 parameters similar to the whole group. However, there was no statistically significant difference between the initial and end values in the group with transport duration of 15 min or below. CONCLUSIONS: Awake hypoxemic patients can be transported without complications in prone position during transport. Transports more than 15 min, prone position may be recommended because the partial oxygen pressure of the patients increases.

Role of lung ultrasonography in the diagnosis of COVID-19 patients admitted to the emergency department.

Introduction: In this study, the use of lung ultrasonography (LUS) to diagnosis lung findings was evaluated in patients with suspected COVID-19 who were admitted to the emergency department (ED). Methods: This observational clinical study was conducted in the ED of the Ankara City Hospital during the period April 1-30, 2020. Patients who were admitted to the ED were triaged as COVID-19 infected and who agreed to undergo LUS/LCT (lung computed tomography) were included in the study. Results: Included in the study were 40 patients who had been prediagnosed with COVID-19. Pneumonia was detected with LCT in 32 (80%) patients, while the LUS examination identified pneumonia in 23 patients. The most common finding in LCT was ground-glass opacity (n = 29, 90.6%). Of the 23 patients with pneumonia findings in LUS, 15 (65.2%) had direct consolidation. Among the 32 patients who were found to have pneumonia as a result of LCT, 20 (62.5%) had signs of pneumonia on LUS examination, and 12 had no signs of pneumonia. In addition, 3 patients showed no signs of pneumonia with LCT, but they were misdiagnosed with pneumonia by LUS. The sensitivity of LUS in the diagnosis of pneumonia in the COVID-19 patients was 62.5%, while its specificity was 62.5%. In addition, its positive predictive value was 87.0%, and its negative predictive value was 29.4%. Conclusion: LUS may also be used in the diagnosis of pneumonia in COVID-19 patients because it is a valuable and accessible bedside diagnostic tool.

Comparison of thiol/disulphide homeostasis with modified Alvarado and RIPASA scores in the diagnosis of acute appendicitis.

BACKGROUND: This study aims to investigate the role of thiol/disulfide homeostasis parameters in the diagnosis of acute appendicitis and to determine whether it is beneficial to use these parameters in combination with the modified Alvarado and RIPASA scoring systems. METHODS: This study was prospectively carried out on 265 patients who presented to the emergency department with the complaint of right lower quadrant pain between 01.07.2017 and 31.12.2017, and met the inclusion criteria of this study. Oxidative stress markers were evaluated on two groups. The relationship between these parameters and the modified Alvarado and RIPASA scoring systems was analyzed. RESULTS: The mean levels of disulfide, disulfide/native thiol and disulfide/total thiol were found to be significantly higher in the appendicitis group (p<0.001). The mean levels of native thiol, total thiol and native thiol/total thiol were significantly lower in the same group (p<0.001, 0.001 and 0.007, respectively). The mean levels of disulfide, disulfide/native thiol and disulfide/total thiol were recorded to be significantly higher in the high-risk group according to the results of RIPASA (p=0.016, 0.003 and 0.001, respectively). CONCLUSION: Thiol/disulfide homeostasis parameters can be used with the modified Alvarado and RIPASA scoring systems in the diagnosis of acute appendicitis.

Tissue adhesives to secure peripheral intravenous catheters: A randomized controlled trial in patients over 65 years.

INTRODUCTION: Peripheral venous catheterization is one of the most used medical procedures in hospitals worldwide. Recent researches state that using intravascular devices is a risk factor for both local and systemic complications. In this study, we aimed to test that addition of tissue adhesive to the insertion site of peripheral intravenous catheters (PIVC) in the emergency department (ED) would reduce the device failure rate at 6 h and 24 h following insertion. MATERIAL AND METHODS: We designed a single-site, two-arm, randomized, controlled trial. We inserted 115 PIVCs into 115 adult patients. RESULTS: PIVC device failure for the 6th hour follow up was 15.4% in the tissue adhesive group (95% CI: 4.1-26.7) vs. 25.6% with standard care group (95% CI: 11.9-39.3). There was no statistically significant difference between two groups (p = 0.33).The number of patients for 24 h follow-up was not enough and the obtained data could not be included in the study. DISCUSSION: In this study, the routine use of tissue adhesives in addition to standard care to reduce PIVC failure for patients 65 years or older in ED was not supported due to not clear benefits and cost effectivity. CONCLUSION: Even though the routine use of tissue adhesives is not recommended according to the study results, it may be reasonable to use tissue adhesives for long term hospitalization expected patients to protect from related complications due to current literature.

Verifying the Placement of Nasogastric Tubes at an Emergency Center: Comparison of Ultrasound with Chest Radiograph.

The objective of this study was to verify the nasogastric tube position with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture and auscultation and to compare the effectiveness of these methods with chest radiography. This is a single-center, prospective, single-blind study. Patients who were admitted to our emergency department and had an indication of nasogastric tube placement were included. Nasogastric tube localization was verified with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture, auscultation, and direct radiography that was accepted as the 'gold standard technique'. A total of 49 patients (27 Male, 22 Female) with a mean age of 58.3±22.7 years were included. Sensitivity of neck ultrasound was 91.5%, and positive predictive value was 100%. As for the subxiphoid ultrasound sensitivity was 78.72%. When neck ultrasound + subxiphoid ultrasound and giving water-air mixture were combined sensitivity reached 95.74%. Sensitivity of neck ultrasound + subxiphoid ultrasound + air-water mixture + auscultation was 97.87% and positive predictive value was 100%. In the light of our results, neck and subxiphoid ultrasound seem to be an alternative method for verifying nasogastric tube localization. Combination of the air-water mixture and auscultation with ultrasound improves the sensitivity.

Investigation of serum thiol/disulphide homeostasis in patients with abortus imminens.

AIM: The aim of our study is to compare serum thiol/disulphide homeostasis of women diagnosed with abortus imminens (AI) and healthy pregnant women, and to determine whether it has a role in the pathogenesis of the disease or not. MATERIALS AND METHODS: A total of 100 pregnant women were included in the study. The study group consisted of 50 patients with AI whereas 50 healthy pregnant women were chosen as the control group. All of the patients in the two groups were matched for age, gestational age, and body mass index. Thiol/disulphide levels were analyzed with a newly developed automated spectrophotometric method. RESULTS: We found significantly reduced levels of native thiol (SH) (370.2 ± 35.2 µmol/l versus 397.6 ± 29.3 µmol/l) and total thiol (406 ± 37.1 µmol/l versus 434.5 ± 29.9 µmol/l), in the sera of the study group compared to the control group (p < .001). But serum levels of disulphide (SS) were statistically insignificant between the two groups (17.9 ± 5.9 µmol/l versus 18.4 ± 4.9 µmol/l, p: .612). Similarly, no significant differences were observed between the two groups in terms of SS/SH, SS/total thiol and SH/total thiol ratios (all p > .05). CONCLUSIONS: We found a decrease in thiol levels which have antioxidant properties in patients with AI. Decreased antioxidant level in the body is thought to play a role in the etiology of AI. In this regard, further studies are needed to elucidate the potential role of dynamic thiol/disulphide homeostasis in the pathogenesis of AI.