The difficult PICC insertion is associated with the significant increase of complications in 1 month follow-up.

BACKGROUND: PICC is routinely inserted with assistance of ultrasonography and/or ECG navigation (RI- routine insertion). Only in a minority of patients the insertion of a PICC is difficult and fluoroscopic visualization with introduction of special guidewire is necessary for the success of the procedure (DI-difficult insertion). The aim of the study was to evaluate whether DI can be predicted and associated with a risk of complications during follow-up. METHODS: The study included patients who had a PICC insertion in 2022. The number of patients with RI and DI was recorded and the significance of selected parameters during insertion and the frequency of complications during 1 month follow-up was compared. RESULTS: About 1404 patients had successful PICC insertion in 2022, RI in 1360 (96.8%) and DI in 44 patients (3.2%). There was no significant effect of age, gender, selected vein, its size, insertion site, and tunneling on the course of PICC insertion. However the number of punctures for needle insertion was higher in DI. The complication rate during 1 month follow-up in DI was 9 (20.4%) versus 101 patients (7.4%) in RI (p = 0.002). CONCLUSION: PICC insertion was successful in both RI and DI patients. Of the analyzed parameters, the number of needle punctures was associated with DI, and complications during the 1-month follow-up were more frequently noted in the DI group.

The selection of the suitable long peripheral catheter in DIVA patients: The significance of ultrasonography.

BACKGROUND: There are several types of LPC (long peripheral catheters) that vary in length, size, insertion method, and cost. The aim of the study was to evaluate whether ultrasonography can be useful for the selection of the suitable LPC in DIVA (difficult intravenous access) patients. METHODS: Based on the ultrasonographic examination, a long peripheral catheter was selected. A 6.4 cm LPC into a vein at a depth of up to 0.5 cm, a 8.5 cm LPC into a vein at a depth up to 1.5 cm, and a 9.8 cm catheter at a depth up to 2 cm using the cannula over needle method. A 12 cm catheter was inserted into the deeper veins using the direct Seldinger method. The catheter diameter was no more than 33% vein diameter. Dwell time and the number of complications of four vascular devices were recorded and compared. RESULTS: One thousand one hundred fifty-six patients, average age 76 years (19-102), 501 men and 655 women, were included in the study. Average dwelling time was 10 days (1-30), there were 136 complications (11.7%). A catheter 6.4 cm long was inserted in 346 (29.8%), 8.5 cm in 140 (12.1%), 9.8 cm in 320 (27, 5%), and 12 cm in 356 (30.6%) patients. There were no significant differences in dwelling time, rate, and type of complications among the four catheters used. CONCLUSION: Our results confirm that ultrasound examination can be useful for the selection of the suitable long peripheral catheter in DIVA patients.

Optimal vascular access to hemodialysis, or what modern medicine offers us.

Hemodialysis is a life-saving method for patients with acute and chronic kidney failure. This treatment requires sufficiently large and safe vascular access. Ensuring optimal vascular access is therefore a prerequisite and an integral part of the care of these patients. In addition to commonly known vascular approaches such as non-tunnelized or tunneled hemodialysis catheters and AV fistulas, less well-known methods are also available, such as a translumbar or directly surgically inserted hemodialysis catheter into the right atrium. However, these alternative approaches are the only, life-saving alternative for some patients. The ambition of this review article is to offer a comprehensive view of the available options for vascular access, the algorithm for its selection and solutions to the most common complications in clinical practice.

Significance of plasma fibrinogen and malondialdehyde in the post-inflammatory period in patients with cystic fibrosis.

OBJECTIVES: Evaluation of selected inflammatory parameters and serum malondialdehyde (MDA) significance in the post-inflammatory period in adult patients with cystic fibrosis. BACKGROUND: Laboratory biomarkers can be integrated into clinical practice as part of monitoring the effectiveness of treatment. METHODS: After recovery from an acute exacerbation of lung infection, selected inflammatory parameters (fibrinogen, IL-1, IL-6, SAA, hs-CRP) and serum MDA were examined in 30 adult patients with cystic fibrosis. Their correlation with FEV1, frequency and duration of subsequent hospitalizations and 6-year prognosis in terms of mortality or need for lung transplantation was evaluated. RESULTS: FEV1 negatively correlated with fibrinogen, but positively with MDA. No significant correlation with hs-CRP, IL-1, IL-6 and SAA was recorded. Plasma fibrinogen predicted the frequency and duration of subsequent hospitalizations. The 6-year prognosis was negatively associated with plasma fibrinogen whereas its association with MDA was positive. However, the prognosis of patients in the multivariate analysis was significantly associated only with FEV1. CONCLUSION: Plasma fibrinogen examined in the post-inflammatory period is a marker of lung damage in patients with cystic fibrosis and can be used to predict the prognosis. The positive correlation of serum MDA with FEV1 in the post-inflammatory period may be important to the interpretation of treatment interventions (Tab. 3, Fig. 2, Ref. 17).

Comparison of 12-cm versus 6-cm long peripheral catheters in patients with difficult intravenous access (DIVA).

BACKGROUND: Long peripheral catheter is 6-15 cm long vascular device. The aim of the study was to compare the frequency of complications of two types of long peripheral catheters with different length inserted in DIVA patients. METHODS: Under ultrasound navigation 2.7F 6.4 cm or 4Fr 12 cm long peripheral catheter was inserted. Complications of both long peripheral catheters were prospectively observed and their relationship to the patient's age, gender, selected vein, number of punctures and Barthel score system was evaluated. RESULTS: Ninety-three 12 cm and fifty-five 6.4 cm long peripheral catheters were inserted. Median of dwelling time was 8 days for 6.4 cm and 9 days for 12 cm long peripheral catheter. There were 17 (26%) complications in 6.4 cm (38/1000 catheter days) and 15 (16%) in 12 cm catheter (17/1000 catheter days), p = 0.04. The complications of both peripheral catheters were not associated with the age of patients, gender, number of punctures and selected vein for insertion. Unlike 12 cm catheter, the complications of 6.4 cm long peripheral catheter were significantly associated with the result of Barthel scoring system (p = 0.003). CONCLUSION: The frequency of complications was more common with 6,4 cm than with 12 cm catheter.

Indications for venous access in oncology - recommendations of national professional societies and current state in the Czech Republic.

BACKGROUND: The aim of the paper is to present the current recommendations and indications of venous access in oncology which reflect and recognize the opinions of national and international professional societies. It focuses exclusively on the indications of intravenous catheter placement for anticancer treatment, such as medium-term and long-term venous accesses. MATERIALS AND METHODS: The survey results obtained from a national questionnaire of 24 oncology centers identified the current situation in the Czech Republic. There were evaluated relevant data on the number of and the criteria for the introduction of venous accesses provided by physicians. Comparisons were made between current oncological practice and recommendations provided by evidence-based medicine. RESULTS: At each center surveyed in the Czech Republic, an average of 130 ports and 80 permanent implanted central catheters are introduced annually. The ports are increasingly indicated, with over a half of the centers surveyed introducing ports to more than 100 patients a year, with four centers introducing a total of 1,600 ports annually. In all centers, the decision for venous access is made by an oncologist. However, most procedures are performed by a doctor of another specialization, most often by a surgeon, a radiologist or an anesthesiologist. More than a half of the indications for venous access placement result from poor peripheral venous system or complications of parenteral therapy, not from comprehensive assessment prior to the initiation of the therapy. CONCLUSION: Based on our findings, we developed general indications and recommendations for venous access to cancer patients which represent the consensus of an interdisciplinary team of specialists, predominantly from the committee of professional societies - the Society for Ports and Permanent Catheters, the Working Group of Nutritional Care in Oncology of the Czech Oncological Society and the Society of Clinical Nutrition and Intensive Metabolic Care. The number of introduced venous access catheters remains insufficient to meet the needs in the Czech Republic, which necessitates increased awareness and possibilities for safe drug administration.

Evaluation of Electrochemical Stability of Sulfonated Anthraquinone-Based Acidic Electrolyte for Redox Flow Battery Application.

Despite intense research in the field of aqueous organic redox flow batteries, low molecular stability of electroactive compounds limits further commercialization. Additionally, currently used methods typically cannot differentiate between individual capacity fade mechanisms, such as degradation of electroactive compound and its cross-over through the membrane. We present a more complex method for in situ evaluation of (electro)chemical stability of electrolytes using a flow electrolyser and a double half-cell including permeation measurements of electrolyte cross-over through a membrane by a UV-VIS spectrometer. The method is employed to study (electro)chemical stability of acidic negolyte based on an anthraquinone sulfonation mixture containing mainly 2,6- and 2,7-anthraquinone disulfonic acid isomers, which can be directly used as an RFB negolyte. The effect of electrolyte state of charge (SoC), current load and operating temperature on electrolyte stability is tested. The results show enhanced capacity decay for fully charged electrolyte (0.9 and 2.45% per day at 20 °C and 40 °C, respectively) while very good stability is observed at 50% SoC and lower, even at 40 °C and under current load (0.02% per day). HPLC analysis conformed deep degradation of AQ derivatives connected with the loss of aromaticity. The developed method can be adopted for stability evaluation of electrolytes of various organic and inorganic RFB chemistries.

The incidence of symptomatic upper limb venous thrombosis associated with midline catheter: Prospective observation.

AIM: The evaluation of the incidence of symptomatic upper limb venous thrombosis (ULVT) associated with midline catheters in patients admitted to the hospital. METHODS: The frequency of symptomatic ULVT diagnosed in a group of patients with midline catheters confirmed by sonographic examination in hospitalised patients at Faculty Hospital over the period of 1 year. RESULTS: Four hundred thirty-nine midline catheters were inserted in 430 patients (250 women and 180 men) during year 2015. Nine patients had two midline catheters. The average age of the patient was 68 years (range: 19-96 years). The median time of midline catheter introduction into a vein was 10 days (range: 1-112 days). Symptomatic thrombosis was diagnosed in 20 patients (4.5%), 3.3/1000 catheter days. It was associated with gender (male) and midline insertion in the cephalic vein. CONCLUSION: The risk of upper limb symptomatic thrombosis associated with midline catheters during a stay in the hospital should be taken into consideration when indicating optimal venous access.

Immunonutrition in patients with cyctic fibrosis leads to drop of serum amyloid A and increase of oxidative stress.

The aim of the present study is to evaluate of the impact of immunonutrition on parameters of oxidative stress and inflammation in patients with cystic fibrosis and malnutrition. In the 30 patients with cystic fibrosis and long-term enteral nutrition support for malnutrition the effect of standard and immunonutrion sipping on oxidative stress and inflammatory activity parameters was compared. Malonyldialdehyde (MDA) as parameter of oxidative stress and serum amyloid A (SAA), interleukin 1 and 6, hsCRP, IgM, IgA, IgG as parameters of inflammatory activity were examined. Immunonutrition decreased SAA to 17.6 mg/L comparing to 25.6 mg/L when standard nutrition was given (p = 0.014). MDA was 0.66 µM on standard and 0.96 µM on immunonutrition support (p<0.01). The significant negative correlation was recorded between MDA and SAA, hs-CRP, interleukin 6, IgA and IgG. In conclusion, the application of immunonutrition in patients with cystic fibrosis and malnutrition is associated with drop of SAA but with the rise of MDA.

[Cardiorenal syndrome - biomarkers and mediators]. / Kardiorenální syndrom - biomarkery a mediátory.

Symptomatic cardiorenal syndrome presents the clinical condition with the serious prognosis when treatment is hardly succesful. A lot of inflammatory and hormonal factors used as biomarkers in clinical practice participate on the initiation, development and progression of cardiorenal syndrome. It means they play role of mediators between heart and kidney and therefore have the significant position in clinical presentation. However the mutual relations between heart and kidney are formed earlier already in the asymptomatic period. The detection of such changes and its correction is the real challenge. The follow-up of hormonal changes and its modulation might be one of the promising approach.Key words: cardiorenal syndrome - biomarker - mediator - inflammatory factors - circulated hormones.

[What is the significance of the phenomenon of hypertension in disguise in patients with type 2 diabetes mellitus treated for long-lasting hypertension?]. / Jaký význam má fenomén "maskované" hypertenze u nemocných s diabetes mellitus 2. typu lécených pro setrvalou hypertenzi?

"Hypertension in disguise" is quite frequent in the patients with diabetes mellitus. It leads to organ damage similarly as persistent hypertension and it is associated with an increased cardiovascular risk which can be reduced through effective treatment. Persistent hypertension is present in 70% of the patients with type 2 diabetes mellitus. During its treatment, the picture of "masked hypertension" may be imitated (normalized blood pressure taken at a day clinic, as opposed to the increased values outside of it). This finding occurs in 35-60 % of the patients with type 2 diabetes mellitus and it is associated with the significance of changes to internal organs. The importance of this finding has been under discussion.

Space GlucoseControl system for blood glucose control in intensive care patients--a European multicentre observational study.

BACKGROUND: Glycaemia control (GC) remains an important therapeutic goal in critically ill patients. The enhanced Model Predictive Control (eMPC) algorithm, which models the behaviour of blood glucose (BG) and insulin sensitivity in individual ICU patients with variable blood samples, is an effective, clinically proven computer based protocol successfully tested at multiple institutions on medical and surgical patients with different nutritional protocols. eMPC has been integrated into the B.Braun Space GlucoseControl system (SGC), which allows direct data communication between pumps and microprocessor. The present study was undertaken to assess the clinical performance and safety of the SGC for glycaemia control in critically ill patients under routine conditions in different ICU settings and with various nutritional protocols. METHODS: The study endpoints were the percentage of time the BG was within the target range 4.4 - 8.3 mmol.l(-1), the frequency of hypoglycaemic episodes, adherence to the advice of the SGC and BG measurement intervals. BG was monitored, and insulin was given as a continuous infusion according to the advice of the SGC. Nutritional management (enteral, parenteral or both) was carried out at the discretion of each centre. RESULTS: 17 centres from 9 European countries included a total of 508 patients, the median study time was 2.9 (1.9-6.1) days. The median (IQR) time-in-target was 83.0 (68.7-93.1) % of time with the mean proposed measurement interval 2.0 ± 0.5 hours. 99.6% of the SGC advices on insulin infusion rate were accepted by the user. Only 4 episodes (0.01% of all BG measurements) of severe hypoglycaemia <2.2 mmol.l(-1) in 4 patients occurred (0.8%; 95% CI 0.02-1.6%). CONCLUSION: Under routine conditions and under different nutritional protocols the Space GlucoseControl system with integrated eMPC algorithm has exhibited its suitability for glycaemia control in critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01523665.

Acid-base disorders associated with serum electrolyte patterns in patients on hemodiafiltration.

BACKGROUND: Metabolic acidosis (MAC) is a common aspect of dialysis-dependent patients. It is definitely caused by acid retention; however, the influence of other plasma ions is unclear. Understanding the mechanism of MAC and its correction is important when choosing the dialysis solution. Therefore, we assessed the relationship between intradialytic change of acid-base status and serum electrolytes. METHODS: We studied 68 patients on post-dilution hemodiafiltration, using dialysate bicarbonate concentration 32mmol/L. The acid-base disorders were evaluated by the traditional Siggaard-Anderson and modern Stewart approaches. RESULTS: The mean pre-dialysis pH was 7.38, standard base excess (SBE) -1.5, undetermined anions (UA(-)) 7.5, sodium-chloride difference (Diff(NaCl)) 36.2mmol/L. MAC was present in 34% of patients, of which 83% had an increased UA(-) as a major cause of MAC. The mean nPCR was 0.99g/kg/day and correlated negatively with SBE. After dialysis, metabolic alkalosis predominated in 81%. The mean post-dialysis pH was 7.45, SBE 4, UA(-) 2.6, Diff(NaCl) 36.9mmol/L. ΔSBE significantly correlated with ΔUA(-), but not with ΔDiff(NaCl) or ΔCl(-). CONCLUSIONS: MAC in patients on hemodiafiltration is mainly caused by acid retention and is associated with higher protein intake. We did not prove the effect of sodium or chloride on acid-base balance. Even though we used a relatively low concentration of dialysate bicarbonate, we recorded a high proportion of post-dialysis alkalosis caused by the excessive decrease of undetermined anions, which had been completely replaced by bicarbonate and indicated the elimination of undesirable anions, as well as of normal endogenous anions.

[Hypersensitive reaction after application of heparin with activation heparin induced trombocytopenia in initiation of intermittent haemodialysis]. / Hypersenzitivní reakce po podání heparinu s aktivací heparinem indukované trombocytopenie po zahájení intermitentní hemodialýzy.

Our report describes the case of patient with hypersensitive reaction regularly arising early after initiation of haemodialysis. This characteristic reaction with pletoric face coloration, bronchospasm, increase of blood pressure, anxiety and decrease of blood oxygen saturation at the consequence and central cyanosis was regularly present without dependence on type of dialysis membrane, drug premedication or prophylactic flushing haemodialysis system by isotonic natrium chloride solution. Low platelet value and trouble-free haemodialysis realized without heparin showed real cause of patients problem. Resolution of this state was regional citrate anticoagulation during intermitent haemodialysis.

Antibiotic treatment following a dog bite in an immunocompromized patient in order to prevent Capnocytophaga canimorsus infection: a case report.

BACKGROUND: Capnocytophaga canimorsus is a commensal bacterium found in the saliva of dogs and cats. Clinically significant infections in humans after a bite are often associated with the presence of immune deficiency. Early recognition and appropriate treatment are crucial for patient survival. In addition, patients with immune deficiency are susceptible to serious life-threatening nosocomial infections, which may also influence the prognosis of patients with Capnocytophaga canimorsus infection. CASE PRESENTATION: A 62-year-old Caucasian female was admitted with septic shock, acute respiratory distress syndrome, acute renal failure, metabolic acidosis and disseminated intravascular coagulation after suffering two small bites from her dog. She had received a splenectomy during childhood. The patient survived after early empiric treatment with antibiotics and intensive supportive care, including ventilation support, a high dose of noradrenalin, and continuous venovenous hemodialysis applied prior to the definitive diagnosis of Capnocytophaga canimorsus sepsis. She improved within 2 weeks but, despite all efforts to prevent nosocomial infection, her hospital course was complicated by Enterococcus species and Candida albicans pleuropneumonia that prolonged her stay in the intensive care unit, and necessitated ventilation support for 2 months. CONCLUSION: Severe Capnocytophaga canimorsus sepsis may be complicated by life-threatening nosocomial infection in immunocompromized patients. The prophylactic application of antibiotics after a dog bite should be considered in high-risk individuals with immune deficiency in order to prevent both Capnocytophyga canimorsus sepsis and serious nosocomial complications.

The optimal control of blood glucose is associated with normal blood pressure 24 hours profile and prevention of the left ventricular remodeling in the patients with gestational diabetes mellitus.

OBJECTIVE: The aim of this study was to evaluate the impact of the optimal diabetes control on the left ventricular parameters and ambulatory blood pressure in women with gestational diabetes mellitus (GDM). METHODS: The patients with GDM were followed up according to predetermined protocol in order to optimize blood glucose and optimal weight gain. Ambulatory blood pressure monitoring (ABPM) and transthoracal and tissue echocardiography were examined in 36th week of pregnancy. RESULTS: The age of 35 women with GDM was 33.1±3 and 30.5±4.4 years in 31 healthy control subjects (p=0.2). Fasting plasma glucose (FPG) in the patients with GDM was 5.0±0.5 mmol/L compared to 4.6±0.3 mmol/L in control subjects (p=0.002). Average weight gain during pregnancy was significantly lower in women with GDM; 10±7.6 kg vs. 13.1±3.7 kg in healthy pregnant women (p=0.05). No significant differences were recorded in 24 hours mean heart rate, systolic and diastolic blood pressure and number of nondippers between both groups. The significant correlation was detected between FPG and blood pressure dipping in subjects with GDM. Interventricular septal, posterior wall and relative wall thickness of the left ventricle were significantly higher in patients with GDM comparing to healthy pregnant women but no significant differences of the left ventricular functions were recorded. CONCLUSION: The optimal control of diabetes in GDM is associated with normal 24 hours blood pressure profile and prevention of the left ventricular function changes in GDM patients. The differences in the left ventricular walls thicknesses may be explained by metabolic changes in GDM.

The significance of plasma adrenomedullin and calcitonin gene-related peptide concentration in patients with Type 2 diabetes mellitus who are treated for cardiovascular risk factors.

OBJECTIVES: To evaluate the significance of plasma adrenomedullin and calcitonin gene-related peptide (CGRP) concentration in patients with Type 2 diabetes mellitus who are treated for hypertension and dyslipidemia. METHOD: Plasma adrenomedullin and CGRP concentration, transthoracal echocardiography and ABPM were evaluated in 82 patients with Type 2 diabetes mellitus and 41 control subjects with no previous cardiovascular disease. All the subjects had casual blood pressure ≤140/90 mmHg or received antihypertensive medication, were treated by statin if LDL cholesterol was≥3mmol/L, by fibrates if triacylglyceroles≥2 mmol/L. RESULTS: The mean age was 61±6 in patients with diabetes mellitus and 61±5 years in control subjects (p=0.9). Plasma CGRP was 3.0±1.8 in patients with diabetes mellitus and 2.3±1.0 ng/ml in control subjects (p=0.09). Plasma adrenomedullin was 2.2±0.9 in patients with diabetes mellitus and 2.8±1.1 ng/ml in control subjects (p=0.01). In patients with diabetes mellitus mass index of the left ventricle was significantly higher and the parameters of diastolic function were more deteriorated. Plasma adrenomedullin and CGRP correlated significantly negatively with serum creatinine and positively with mean 24 hours arterial blood pressure in patients with diabetes mellitus but not in control subjects. Plasma adrenomedullin concentration in patients with diabetes mellitus treated for hypertension was significantly reduced. CONCLUSION: Despite concentration plasma adrenomedullin and CGRP modulation by cardioprotective treatment both neuropeptides remained involved in regulation of hemodynamic and metabolic parameters in patients with Type 2 diabetes mellitus. The low plasma of adrenomedullin in patients with Type 2 diabetic may be marker of the efficient intervention on cardiovascular risk factors.

Effects of high-tone external muscle stimulation on renal function in healthy volunteers.

OBJECTIVE AND DESIGN: Hightone external muscle stimulation (HTEMS) ameliorates pain and discomfort of patients with polyneuropathy. Since some patients reported about an urge to urinate during these treatments, the potential effects of HTEMS application on renal function were investigated. For this purpose in healthy subjects, we analyzed in the current study the acute effects of electrotherapy on parameters of renal function. INTERVENTIONS: 24 healthy volunteers (14 women and 10 men), mean age 26 ± 4 years, were enrolled. The protocol was composed of a run-in period, a pre-treatment period, the active HTEMS treatment period of both lower extremities and the post-treatment period. The duration of each period was 60 min. Urine collection and blood samples were taken at the beginning and end of each period. To achieve a sufficient diuresis, the fluid intake was adapted to the amount of diuresis. Parameters of renal function included diuresis, glomerular filtration rate (endogenous creatinine clearance) and absolute and fractional sodium excretion. Moreover blood pressure and heart rate were monitored. RESULTS: HTEMS led to a significant increase of creatinine clearance and fractional sodium excretion which was limited to the active treatment period. CONCLUSION: These findings show for the first time that HTEMS can transiently increase glomerular filtration rate associated with a decreased tubular sodium reabsorption. The underlying mechanisms are to be elucidated.