Positive end-expiratory pressure lung recruitment: comparison between lower inflection point and ultrasound assessment.

BACKGROUND: Maintenance of the open lung alveoli in the expiration on mechanical ventilation in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) remains challenging despite advances in lung imaging. The inspiratory lower inflection point (LIP) on the ventilator pressure-volume (P-V) curve estimates the required end-expiratory pressure for recruitment of alveolar consolidation. Alternatively, the end-expiratory pressure for recruitment of crater-like subpleural alveolar consolidation could be simply followed with ultrasound. These two methods for setting the ventilators positive end-expiratory pressure (PEEP) were compared. METHODS: The observational study in surgical/neurosurgical intensive care between October 2009 and November 2011 included 17 deeply sedated or relaxed patients. LIP was measured with continuous low-flow method, as a pressure in cmH(2)O. Expiratory levelling between lower border of subpleural consolidation and adjacent pleural line, which means lung recruitment, was followed with linear ultrasound probe. PEEP in cmH(2)O at which the levelling occurs was compared with LIP pressure. RESULTS: LIP pressure never exceeds the PEEP for recruitment of subpleural consolidations followed with ultrasound. A significant correlation (r = 0.839; p < 0.05) was found between two methods. CONCLUSIONS: In this study, positive end-expiratory pressures for recruitment of subpleural consolidations followed by ultrasound always exceed the pressures measured with LIP. Respecting this, ultrasound method could be the guide for PEEP lung recruitment.

Ultrasonographic finding of lung sliding in patients on mechanical ventilation with alveolar-interstitial syndrome.

BACKGROUND AND OBJECTIVES: To determine the visibility of pleural lung sliding in alveolar-interstitial syndrome (AIS) in patients on mechanical ventilation at two different time points, as a confirmatory ultrasonographic method for excluding pneumothorax. METHODS: Fifty-two mechanically ventilated patients in the semirecumbent position in a surgical/neurosurgical intensive care unit with ultrasonographic lung 'comet tails' in three upper anterolateral intercostal spaces, indicating the presence of AIS, were scanned for lung sliding in the same three intercostal spaces with a linear 5-10 MHz transducer after starting mechanical ventilation and on weaning trials. Pneumothorax and atelectasis were excluded by chest radiograph. RESULTS: Absent lung sliding was found in 22.7% of intercostal spaces scanned after starting mechanical ventilation and in 21.2% of scans taken on weaning trials. The lowest invisible rate was in patients with acute heart failure and the highest in patients with acute respiratory distress syndrome. CONCLUSION: Lung sliding specificity in AIS during mechanical ventilation was 78%. Our opinion is that different levels of airway pressure between starting mechanical ventilation and weaning trials have no influence on lung sliding visibility.

Anesthetic management of patients undergoing pituitary surgery.

Pituitary tumors account for more than 10% of all intracranial tumors. They often present with symptoms of hormonal hypersecretion, although they may also cause hypopituitarism. Transsphenoidal pituitary surgery has become a commonly performed neurosurgical procedure, which has certain challenges for the anesthesiologist due to many distinct comorbidities associated with various adenomas. This article provides a review of perioperative concerns regarding transsphenoidal pituitary surgery, encountered in a number of these patients. Thorough understanding of preoperative assessment, intraoperative management and potential complications is fundamental for successful perioperative patient care and avoidance of morbidity and mortality.

Organ donation from a patient with bacterial meningoencephalitis -- the first case in Croatia.

The growing number of patients with terminal organ failure waiting for transplantation and the limited number of available organs demand that explantation teams see brain-dead patients with infectious diseases such as bacterial meningoencephalitis as potential donors, although until recently organ explantation from such donors has been contraindicated. This paper presents the first case of successful organ explantation from a donor with confirmed bacterial meningoencephalitis in our country. In this previously healthy patient (only with mild arterial hypertension in personal history), bacterial meningoencephalitis caused fulminant worsening and he deteriorated from mild disorder of consciousness (GCS 12) to brain death within only 24 hours. After the transplantation of organs was performed (heart, kidneys, liver and corneas were explanted), antibiotic therapy was continued in all organ recipients and two days after the transplantation none of the recipients showed any signs of infectious complications. This paper proves that this type of patients should also be treated as potential donors, under condition of appropriate microbiological diagnosis, antibiotic therapy and sustained hemodynamic stability, which should enlarge the number of organs available for transplantation.

Constant cardiac output monitoring using the PiCCO and LiDCO methods versus PAK in septic patients: when to do calibration?

The accuracy of cardiac output measurement by two most widely used methods of less invasive hemodynamic monitoring and by the standard technique of thermodilution with pulmonary catheter was assessed. The measurements were carried out in septic surgical patients immediately after and between system calibrations. Study results showed satisfactory compatibility of measurements performed by the two methods and by pulmonary catheter in both phases, thus system calibration being recommendable in hemodynamically unstable septic patients.

Increased donor rate at Sestre milosrdnice University Hospital.

The rate of organ donation reflects the level of the respective society and country development. In Croatia, attempts have been made to increase this rate. As a consequence, the number of potential donors with confirmed brain death was observed to have steadily increased during the 2004-2008 period. Data on all potential donors where the confirmation procedure for brain death was completed were retrieved and analyzed. The percentage of donors out of all persons diagnosed with brain death and all deaths recorded at the Central Intensive Care Unit and at all Hospital departments was calculated. The mean number or organs per donor was also calculated. During the 2004-2008 period, the number of donors perbrain death persons was 5/unknown, 6/10, 8/13, 11/13 and 18/20; mean age 51, 50, 39, 48 and 44; donor rate per Central Intensive Care Unit deaths 5.9%, 5.6%, 5.8%, 10.4% and 12.1%; donor rate per all hospital deaths 0.4%, 0.5%, 0.5%, 1.5% and 1.9%; and number of organs per donor 1.6, 2.4, 2.6, 3.0 and 2.7, respectively. Study results showed a steady increase in the number of donors and organs per donor at Sestre milosrdnice University Hospital during the 2004-2008 period. More intensive education should be organized at medical schools and for medical professionals to identify brain death persons and potential donors. In addition, mass media campaigns should improve public awareness and perception of the issue.

[Usefulness of transcranial Doppler in brain death confirmation]. / Uporabljivost transkranijskog doplera u potvrdi mozdane smrti.

Brain death is a clinical diagnosis and must be confirmed by one paraclinical test. This report presents the usefulness of paraclinical tests applied during a 4-year period. Forty-four patients with severe brain lesions leading to brain death were treated during the 2004-2007 period. The appropriate test was chosen according to test availability and patient condition, appreciating restrictions according to the test protocol. Since the results of some tests were inconclusive, some patients underwent repeat testing with the same or different methods. Among 44 patients, 19 had neurotrauma, 11 massive aneurysmal subarachnoid hemorrhage, 1 massive arteriovenous subarachnoid and parenchymal hemorrhage, 12 hypertensive parenchymal hemorrhage, and 1 ischemic stroke. As a primary test, transcranial Doppler (TCD) was used in 30, brain scintigraphy in 2, multislice computed tomography angiography (MSCTA) in 10, and cerebral angiography in 2 patients; the diagnosis was confirmed in 26, 3, 9 and 2 patients, respectively. Due to inconclusive test results, MSCTA had to be repeated in 4 patients twice, and in one patient three times. Four patients where TCD was used died during the observation period, and in one patient the hemodynamic spectrum was inconclusive. In most patients (65%), TCD confirmed the clinical diagnosis of brain death, and in 61% the diagnosis was confirmed within a 2-hour period. TCD was the most useful confirmatory test for cerebral circulatory arrest in brain death diagnosis.

Plasma interleukin-8 as a potential predictor of mortality in adult patients with severe traumatic brain injury.

Because of complex pathophysiology and severe consequences, traumatic brain injuries (TBI) are an important medical problem. Pathophysiology of TBI includes local and systemic stress response, in which interleukin-8 (IL-8) is considered as a key mediator of neuroinflammation. However, prognostic relevance of IL-8 measurement in adult patients with severe TBI is not certain. Therefore, IL-8 was determined in blood samples from central venous and jugular bulb catheter and in cerebrospinal fluid of twenty patients with isolated TBI at admission to Intensive Care Unit. None of the patients had history of stroke, dementia, autoimmune diseases, acute infection or medication with anti-inflammatory drugs. Ten patients died due to traumatic brain injury, while the other ten recovered well. While there was no significant difference of IL-8 levels in cerebrospinal fluid between survivors and nonsurvivors, central venous plasma level of IL-8 was significantly lower in survivors (71.00 +/- 14.17 pg/ml), than in nonsurvivors (111.26 +/- 16.9 pg/ml). Receiver Operating Characteristic (ROC) analysis revealed significant prognostic value for IL-8 in the blood as well as for the age of patients, Glasgow Coma Scale (GCS) and Acute Physiologic and Chronic Health Evaluation (APACHE II). These findings suggest that the central venous plasma values of IL-8 at admission might be an early predictive marker in patients with severe TBI, comparative to standard clinical prognostic markers such as APACHE II and GCS.