ABSTRACT
Angiotensin II (AT) is a potent vasoconstrictor and hypertensive drug that is registered for the treatment of severe hypotension in vasoplegic shock. Growing experience with the use of AT in cardiac surgery allows the first therapeutic algorithms to be created. This paper is a proposal for the use of AT in distributive shock after extracorporeal circulation.
ABSTRACT
The present study aimed to assess the changes in the immunological parameters of patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The serum or plasma samples of patients were assessed to determine the concentrations of IL-6, one of the major proinflammatory cytokines (seven females and six males), and selected classes of immunoglobulins (six females and seven males). The samples for ELISA (enzyme-linked immunosorbent assay) were collected from patients before the use of CPB, at 60 min of the use of CPB, and at 24 h after the surgery. After 24 h of the surgery, IL-6, IgM, and IgG concentrations were higher in the serum of female patients than in the serum of male patients. However, compared to female patients, male patients showed a significant increase in IgG3 concentration after 24 h of the surgery. Regardless of age, the levels of the analyzed classes of immunoglobulins were similar in all patients. Additionally, in both age groups, a significant increase in the serum IL-6 concentration was observed after the first postoperative day, and this increase was more pronounced in patients diagnosed to have postoperative infections. The serum IL-6 concentration can serve as a potential marker of pathogenic infections in patients undergoing cardiac surgery with CPB and is thus useful for the early diagnosis of postoperative infections.
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The debate on limiting futile therapy in the aspect of End of Life (EoL) care has been going on in Poland over the last decade. The growing demand for EoL care resulting from the aging of societies corresponds to the expectation of a satisfactory quality of life and self-determination. The authors designed a cross-sectional study using a newly designed questionnaire to assess the opinions of 190 nurses employed in intensive care units (ICUs) on futile therapy, practices, and the respondents' approach to the issue. The problem of futile therapy and its clinical implications are known to the nursing community. Among the most common reasons for undertaking futile therapy in adult patients, the respondents declared fear of legal liability for not taking such actions (71.58%), as well as fear of being accused of unethical conduct (56.32%), and fear of talking to the patient/patient's family and their reaction (43.16%). In the case of adult patients, the respondents believed that discontinuation of futile therapy should be decided by the patient (84.21%), followed by a doctor (64.21%). As for paediatric patients, two-thirds of the respondents mentioned a doctor and a court (64.74% and 64.21%, respectively). Overall, 65.26% of the respondents believe and agree that the comfort of the patient's last days is more important than the persistent continuation of therapy and prolonging life at all costs. The presented results clearly show the attitude of the respondents who defend the patient's dignity and autonomy.
Subject(s)
Attitude of Health Personnel , Nursing Staff , Adult , Humans , Child , Cross-Sectional Studies , Poland , Quality of Life , Surveys and QuestionnairesABSTRACT
The debate about medical futility often involves intensive care units where life-support procedures are routinely applied. Futile therapy is part of end-of-life therapy. In the discussion about medical futility it is important to distinguish the effect of therapy from the benefit for the patient. The goal of treatment is not to maintain the function of an organ, body part or physiological activity, but to maintain health as a whole. Prolonging ineffective treatment violates the standard of good medical practice. In 2014, the first Polish guidelines on limiting futile therapy in patients treated in intensive care units were published. This document presents the official position of intensive care experts consulted by medical societies of other medical disciplines. Limitation of futile therapy by withdrawing from already used treatments or withholding new therapies does not mean that the role of medical personnel has ended. Intensive care turns into palliative care. The list of comorbidities showing a statistically significant correlation with medical futility has been refined. These include heart failure (NYHA III/IV), neoplastic disease and disseminated neoplastic process, and failure of two or more organs. The published survey results are devastating; 66-89% of intensive care nurses have provided futile treatment in their careers. Intensivists estimated that, on average, 20% of patients in intensive care units receive futile therapy. There is a need to disseminate standards and procedures related to end-of-life care in Polish intensive care units.
Subject(s)
Medical Futility , Terminal Care , Critical Care , Humans , Intensive Care Units , Palliative CareABSTRACT
PURPOSE: Flexible bronchoscopy (FB) causes airway narrowing and may cause respiratory failure (RF). Noninvasive mechanical ventilation (NIV) is used to treat RF. Until recently, little was known about noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) risk and complications. MATERIALS AND METHODS: A retrospective analysis of NIV-FB performed in 20 consecutive months (July 1, 2018-February 29, 2020) was performed. Indications for: FB and NIV, as well as impact of comorbidities, blood gas results, pulmonary function test results and sedation depth, were analyzed to reveal NIV-FB risk. Out of a total of 713 FBs, NIV-FB was performed in 50 patients with multiple comorbidities, acute or chronic RF, substantial tracheal narrowing, or after previously unsuccessful FB attempt. RESULTS: In three cases, reversible complications were observed. Additionally, due to the severity of underlining disease, two patients were transferred to the ICU where they passed away after >48h. In a single variable analysis, PaO2 69 â± â18.5 and 49 â± â9.0 [mmHg] (p â< â0.05) and white blood count (WBC) 10.0 â± â4.81 and 14.4 â± â3.10 (p â< â0.05) were found predictive for complications. Left heart disease indicated unfavorable NIV-FB outcome (p â= â0.046). CONCLUSIONS: NIV-FB is safe in severely ill patients, however procedure-related risk should be further defined and verified in prospective studies.
Subject(s)
Noninvasive Ventilation , Respiration, Artificial , Bronchoscopy/adverse effects , Humans , Noninvasive Ventilation/adverse effects , Prospective Studies , Respiration, Artificial/adverse effects , Retrospective Studies , Risk FactorsABSTRACT
The coronavirus disease (COVID-19) was previously unknown, and we are learning about it day by day, but pandemic-associated ethical dilemmas have been studied and discussed for years. Triage means not only ranking in terms of importance (prioritisation) but also allocation of limited medical resources. Survival, post epidemic-quality of life, and consumption of medical resources required to achieve the set goal are crucial for making triage decisions. The pandemic triage decisions should be based on a protocol, considering the need for medical measures and therapy benefits. The first step is to consider the exclusion criteria and the risk of death. The next step is sequential clinical assessment, repeatable at defined intervals. It seems that the preferable solution is to triage all the patients and give priority to those who would benefit more. A prerequisite for allocating insufficient medical resources is public trust in the criteria for allocation.
Subject(s)
Coronavirus Infections , Pandemics , Pneumonia, Viral , Triage/trends , COVID-19 , Clinical Decision-Making , Humans , Triage/statistics & numerical dataSubject(s)
Coronavirus Infections , Pandemics , Pneumonia, Viral , Respiratory Distress Syndrome , Betacoronavirus , COVID-19 , COVID-19 Testing , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Humans , Respiratory Distress Syndrome/diagnosis , Reverse Transcriptase Polymerase Chain Reaction , SARS-CoV-2ABSTRACT
Levosimendan is a new inodilator which involves 3 main mechanisms: increases the calcium sensitivity of cardiomyocytes, acts as a vasodilator due to the opening of potassium channels, and has a cardioprotective effect. Levosimendan is mainly used in the treatment of acute decompensated heart failure (class IIb recommendation according to the European Society of Cardiology guidelines). However, numerous clinical trials indicate the validity of repeated infusions of levosimendan in patients with stable heart failure as a bridge therapy to heart transplantation, and in patients with accompanying right ventricular heart failure and pulmonary hypertension. Due to the complex mechanism of action, including the cardioprotective and anti- -aggregating effect, the use of levosimendan may be particularly beneficial in acute coronary syndromes, preventing the occurrence of acute heart failure. There are data indicating that levosimendan administered prior to cardiac surgery may improve outcomes in patients with severely impaired left ventricular function. The multidirectional mechanism of action also affects other organs and systems. The positive effect of levosimendan in the treatment of cardiorenal and cardiohepatic syndromes has been shown. It has a safe and predictable profile of action, does not induce tolerance, and shows no adverse effects affecting patients survival or prognosis. However, with inconclusive results of previous studies, there is aneed for awell-designed multicenter randomized placebo-controlled study, including an adequately large group of outpatients with chronic advanced systolic heart failure.
Subject(s)
Heart Failure , Pyridazines , Cardiotonic Agents/therapeutic use , Expert Testimony , Heart Failure/drug therapy , Humans , Hydrazones/therapeutic use , Poland , Pyridazines/therapeutic use , SimendanABSTRACT
INTRODUCTION: Over the last two decades transcatheter aortic valve replacement (TAVR) has been approved for clinical use. The anaesthetic choice for this procedure is evolving. General anaesthesia was the predominant anaesthetic technique. Growing experience and advances in technology and economic considerations have led to an increasing interest in performing TAVR under monitored sedation. AIM: The assessment of monitored sedation, called cooperative sedation, involves pharmacologically mediated suppression of consciousness and preservation of verbal contact in response to stimulation as a safe method of anaesthesia for TAVR. MATERIAL AND METHODS: Sixty out of 63 TAVR patients with femoral access received monitored sedation. Dexmedetomidine was administered in most of such cases (46 patients). A questionnaire was also carried out by staff involved in performing TAVR procedures, with more than 5 years of experience in it, concerning the method of anaesthesia and perioperative care. RESULTS: Conversion to general anaesthesia was required in 10% of patients (6 cases), only one as a patient-related complication (hypercarbia). The questionnaire carried out showed that anaesthesia and postoperative care after TAVR are underestimated. CONCLUSIONS: The preliminary results regarding anaesthetic management in TAVR procedures demonstrate that monitored sedation is safe, provided that contraindications are observed.
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BACKGROUND: The search for ideal anaesthesia is still an open research issue. The aim of the study was to evaluate and compare two methods of general anaesthesia with preserved own breath - propofol with ketamine and propofol with remifentanil - in children anaesthetized for gastroscopy. METHODS: The study included 90 children enrolled for elective endoscopy of the upper gastrointestinal tract under general anaesthesia. The patients were randomized to one of two groups: Group K consisted of children anesthetized with propofol and ketamine, Group R included children anesthetized with propofol and remifentanil. Parameters monitored during anaesthesia were induction time, respiratory and circulatory parameters, adverse events, waking time and the child's condition after regaining consciousness. RESULTS: The groups differed significantly in time of induction of anaesthesia (Group K 3 ± 1 min vs. Group R 4 ± 2.5 min; P < 0.001), waking time (Group R 4 ± 4.5 min vs. Group K 6 ± 5 min; P < 0.01), condition of the child after regaining consciousness (Group R 90.9% calm, Group of K 54% confused; P < 0.001) and evaluation of test conditions in the opinion of the gastroenterologist (in favour of Group K; P < 0.05). CONCLUSIONS: Both methods of anaesthesia presented in the paper are safe and can be used in children to perform endoscopy. Combining propofol with ketamine allows fast induction of anaesthesia and creates very good conditions for the examination. Combining propofol with remifentanil allows fast and full return of consciousness after anaesthesia.
Subject(s)
Gastroscopy/methods , Ketamine/administration & dosage , Propofol/administration & dosage , Remifentanil/administration & dosage , Adolescent , Anesthesia Recovery Period , Anesthetics, Combined/administration & dosage , Anesthetics, Combined/adverse effects , Anesthetics, Dissociative/administration & dosage , Anesthetics, Dissociative/adverse effects , Anesthetics, Intravenous/administration & dosage , Anesthetics, Intravenous/adverse effects , Child , Child, Preschool , Female , Humans , Ketamine/adverse effects , Male , Propofol/adverse effects , Remifentanil/adverse effects , Single-Blind Method , Young AdultABSTRACT
BACKGROUND Patients under 30 years of age constitute a unique population in the Intensive Care Unit (ICU). The aim of this study was to obtain information on young adults admitted to Polish ICUs and to identify independent predictors of favorable outcome in this population. MATERIAL AND METHODS Data from 20 651 adult patients from the Silesian Registry of Intensive Care Units conducted in the Silesian Region of Poland since October 2010 were analyzed. Patients aged 18-29 years were identified and their data were compared to the remaining population. Preadmission and admission variables that independently influence the favorable outcome (defined as survival of ICU stay and discharge in a condition other than vegetative state or minimally conscious state) were identified. RESULTS Among 20 609 analyzed adult patients, 850 (4.1%) were under the age of 30 years. Young adults had a lower mean APACHE II and SAPS III score at admission and were more frequently admitted to the ICU due to trauma, poisonings, acute neurological disorders, and obstetric complications. ICU mortality was over 2 times lower (20.1% vs. 45.3%, p<0.001). Independent variables affecting favorable outcome in this population were: admission to ICU from the operating theatre and multiple trauma as a primary cause of admission. CONCLUSIONS The greater chance of favorable outcome in adults under the age of 30 years admitted to the ICU is due to their unique characteristics. Favorable outcome in young adults is most likely among patients admitted to the ICU following multiple trauma or admitted from the operating theatre.
Subject(s)
Intensive Care Units/trends , Prognosis , Treatment Outcome , APACHE , Adult , Female , Hospital Mortality , Hospitalization , Humans , Length of Stay , Male , Patient Discharge , Poland , Registries , Retrospective Studies , Simplified Acute Physiology Score , Young AdultABSTRACT
The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient's satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.
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BACKGROUND: The aim of this paper is to describe the third pregnancy trimester, delivery and puerperium in patient with idiopathic pulmonary hypertension. CASE REPORT: a 30-year-old primigravida with idiopathic pulmonary hypertension was qualified for emergency Caesarean section. In the post partum period no improvement in managing pulmonary arterial hypertension was achieved. Because of progressive respiratory and circulatory failure as well as the pulmonary artery pressure exceeding the systemic pressure the AV ECMO was applied on postoperative day 6. During the ECMO period the emergency laparotomy due to bleeding was necessary. The further course of ICU treatment was uneventful. CONCLUSION: In described case things are left to chance or goodwill of specialists and final outcome depend on happy coincidences.
Subject(s)
Cesarean Section , Emergencies , Familial Primary Pulmonary Hypertension/therapy , Pregnancy Complications, Cardiovascular/therapy , Adult , Extracorporeal Membrane Oxygenation , Female , Humans , Infant, Newborn , Male , Postnatal Care , PregnancyABSTRACT
INTRODUCTION: Monitoring lung function during pneumonia is essential for the evaluation of the effectiveness of therapy in ICU patients. Among various bedside techniques, two particularly interesting are the lung ultrasound and the transpulmonary thermodilution technique. In this observational single center study we want to assess the correlation between the lung ultrasound examination (LUS) and transpulmonary thermodilution volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). MATERIAL AND METHODS: We analyzed data obtained from medical history of twelve patients requiring mechanical ventilation and hemodynamics monitoring with PICCO catheter due to newly diagnosed pneumonia. We compared lung ultrasound examination performed on the first and third day of new antimicrobial therapy with results of transpulmonary thermodilution examination made on same day. We also calculate the difference between values obtained on first and third day to compare the trends. RESULTS: We did not find any association between tested variables, except a correlation between PVPI and EVLWI, both measured at the same day (Rho = 0.3; 95%CI -0.02-0.59; p = 0.03), and trends in the period of 3 days (Rho = 0.6; 95%CI 0.2-0.8; p = 0.005). CONCLUSIONS: The results of the study indicate that volumetric values achieved using the PiCCO method as well as lung ultrasound should be interpreted with care and related to the clinical state of a patient, keeping in mind that no correlation between the result achieved and the actual state of inflammatory changes in the lungs may be possible.
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INTRODUCTION: Significant impairment of left ventricular function causes low cardiac output syndrome in the immediate postoperative period in 3-14% of patients undergoing surgery, increasing the mortality 15-fold. AIM: To assess the use of levosimendan in patients undergoing cardiac surgery in 2016. MATERIAL AND METHODS: The analysis included 14 patients: 3 (21.4%) women and 11 (78.6%) men aged 65.4 ±11.8 years. The mean value of left ventricular ejection fraction amounted to 20 ±6.25%. In 11 patients, levosimendan infusion was started immediately after the induction of anesthesia. Three patients received the agent during the early postoperative period due to low cardiac output syndrome refractory to conventional therapy. The dosage was modified within the range of 0.05-0.2 µg/kg/min. On the day of the surgery, all patients received continuous infusion of adrenaline and levonor. RESULTS: The cardiac index amounted to 2.8 ±0.71 l/m2 after several hours of infusion and 2.9 ±0.1 l/m2 the next morning. The first examination showed that the mean systemic vascular resistance was 1010 dyn/s-5 and the second: 940 ±100 dyn/s-5; mixed venous blood saturation amounted to 66 ±7.5% and 65.5 ±8%, respectively. Respectively, the mean concentration of lactates was 2.0 ±0.96 mmol/l and 1.8 ±0.24 mmol/l. Mechanical lung ventilation lasting more than 48 hours was required in 50% of the patients. Two patients with chronic kidney disease required bedside renal replacement therapy before the procedure. Two (14.3%) patients died. Nine (64.3%) patients were discharged home, and three were transferred to cardiac wards. CONCLUSIONS: Levosimendan therapy proved safe in the study group. The nature of the study and the small sample size preclude the formulation of detailed conclusions.