Association between disease-related malnutrition and innate immunity gene expression in critically ill patients at intensive care unit admission.

The aim of the study was to analyse the relationship between nutritional disorders and the expression of innate antibacterial response genes in patients admitted to the intensive care unit (ICU). In 46 patients with severe malnutrition and life-threatening surgical complications, nutritional status tests were performed on the basis of the NRS 2002 (Nutritional Risk Screening) scale, cytokine, albumin, C-reactive protein concentrations, anthropometric tests, and body composition analysis. Concurrently, the expression of Toll-like receptor 2, NOD1, TRAF6, and HMGB1 genes was determined in peripheral blood leukocytes at the mRNA level using real-time polymerase chain reaction. It was found that both the nutritional status and the gene expression changed depending on the group of patients studied (including the group of survivors vs. non-survivors). Significant correlations were found between the results of routine tests used in the diagnostics of malnutrition (including NRS 2002, resistance, reactance, phase angle, excess of extracellular water) and the expression of the studied genes. Moreover, the expression of TRAF6 and HMGB1 genes correlated with the Acute Physiology and Chronic Health Evaluation II scale and the age of the patients. The results of the research suggest that the expression of innate antibacterial response genes may be a new diagnostic tool complementing the assessment of nutritional disorders in surgical patients admitted to the ICU. These tests may be helpful in providing more accurate diagnostics of the genetic effects of malnutrition and in the monitoring of patients for whom nutritional treatment is planned to support the functions of the immune system, thereby increasing the effectiveness of this type of treatment in the ICU.

ICU mortality and variables associated with ICU survival in Poland: A nationwide database study.

BACKGROUND: Recently published international comparison data across European countries revealed high mortality rates in Polish ICUs. OBJECTIVES: Estimation of the rate of ICU mortality and identification of variables associated with ICU survival in Poland. DESIGN: Retrospective analyses of a database reporting ICU stays in Poland. SETTINGS AND PATIENTS: The study included data from all adult patients admitted to an ICU in Poland from 1 January 2012 to 31 December 2012. MAIN OUTCOME MEASURES: ICU mortality and variables associated with ICU survival. RESULTS: A total of 48 282 patients were treated in 347 ICUs (mean age 63.1 ±â€Š16.8 years, 59% men) with 20 278 deaths (42.0%). Variables associated with ICU survival were: tertiary level of hospital care [relative risk (RR) 0.86, 95% confidence interval (CI) 0.80 to 0.92, P < 0.001]; high annual patient volume in the ICU (RR 0.9995 patient year, 95% CI 0.9994 to 0.9996, P < 0.001); younger patient age (RR 1.025 year, 95% CI 1.024 to 1.026, P < 0.001); female sex (RR 0.92, 95% CI 0.88 to 0.96; P < 0.001); and lower number of comorbidities (RR 1.33, 95% CI 1.31 to 1.35, P < 0.001). CONCLUSION: ICU mortality was high in Poland. Structural variables, such as the level of hospital care and annual patient volume, may be associated with ICU survival.

Perioperative bleeding in patients undergoing liver transplantation.

Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years or so, significant progress in surgical techniques and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during LT have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.

Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition.

The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells).

Prognostic scoring systems for mortality in intensive care units--the APACHE model.

The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system is time consuming. The mean time for introducing a patient's data to APACHE IV is 37.3 min. Nevertheless, statisticians have known for years that the higher the number of variables the mathematical model describes, the more accurate the model. Because of the necessity of gathering data over a 24-hour period and of determining one cause for ICU admission, the system is troublesome and prone to mistakes. The evolution of the APACHE scoring system is an example of unfulfilled hopes for accurately estimating the risk of death for patients admitted to the ICU; satisfactory prognostic effects resulting from the use of APACHE II and III have been recently studied in patients undergoing liver transplantations. Because no increase in the predictive properties of successive versions has been observed, the search for other solutions continues. The APACHE IV scoring system is helpful; however, its use without prepared spreadsheets is almost impractical. Therefore, although many years have passed since its original publication, APACHE II or its extension APACHE III is currently used in clinical practice.

Usability of ultrasound assessment of gastric content. Case reports.

The paper presents the use of ultrasound assessment of gastric content in anesthesiological practice. Factors influencing pulmonary aspiration of gastric content and the risk of a complication in the form of aspiration pneumonia are discussed. The examination was performed on two patients hospitalized in a state of emergency who required surgical intervention. The first patient, a 46-year-old male with a phlegmon of the foot, treated for type 2 diabetes, ischemic heart disease and renal insufficiency, required urgent incision of the phlegmon. The second patient, a 36-year-old male with a post-traumatic pericerebral hematoma, qualified for an urgent trepanation. Interviews with the patients and their medical documentation indicated that they had been fasting for the recommended six hours before the surgery. However, during a gastric ultrasound examination it was found that food was still present in the stomach, which caused a change in the anesthesiological procedure chosen. The authors present a method of performing gastric ultrasound examination, determining the nature of the food content present and estimating its volume.

Will transoesophageal echocardiography become a standard tool for anesthetists to assess haemodynamic status during non-cardiac surgeries? Case report and literature review.

A 53-year-old male, with no history of cardiovascular diseases, underwent elective extended right hemihepatectomy for large metastatic tumor. Approximately 2 hours after the start of procedure sudden onset of severe hypotension associated with profound desaturation and significant fall in end-tidal carbon dioxide pressure was noted. Transoesophageal echocardiography was performed and massive air embolism was confirmed. Patient was turned into Trendelenburg position, inspired oxygen was increased to 100% and positive end-expiratiory pressure turned up to 10 cm H20. Patient was further resuscitated with iv fluids, blood products and vasopressors under surveillance of transoesophageal echocardiography. In this report we present a case in which intraoperative use of transoesophageal echocardiography by trained anaesthetist helped to immediately identify the cause of sudden hypotension and hypoxaemia. Transoesophageal echocardiographywas also a valuable tool for direct monitoring of efficacy of instituted treatment.

Mortality scoring in ITU.

Chronic shortage of ITU beds makes decisions on admission difficult and responsible. The use of computer-based mortality scoring should help in decision-making and for this purpose, a number of different scoring systems have been created; in principle, they should be easy to use, adaptable to all populations of patients and suitable for predicting the risk of mortality during both ITU and hospital stay. Most of existing scales and scoring systems were included in this review. They are frequently used in ITUs and become a necessary tool to describe ITU populations and to explain differences in mortality. As there are several pitfalls related to the interpretation of the numbers supplied by the systems, they should be used with the knowledge on the severity scoring science. Moreover, the cost and significant workload limit the use of scoring systems; in many cases an extra person has to be employed for collection and analysis of data only.

[The skin incisions (blow holes) for treatment of massive subcutaneous emphysema]. / Blow holes ­ metoda leczenia masywnej odmy podskórnej .

BACKGROUND: Subcutaneous emphysema (SE) is rarely life-threatening, although it may create significant discomfort to patients. It may impede eye opening, movement of the limbs and sometimes causes stridor and respiratory distress. We describe two cases of SE, in which small incisions in the skin helped to relieve symptoms. CASE REPORTS: Case 1. A 64-year-old male was admitted to ITU, having been intubated after blunt chest trauma during a traffic accident. Initial presentation included respiratory failure, massive SE of the face, neck and chest, and fractured ribs with bilateral pneumothorax and bilateral lung contusion. Ventilation with BiPAP with 15 cm H2O PEEP was commenced and a right chest drain was inserted. This resulted in rapid improvement of gas exchange, but SE became progressively larger. On the second day, several 2 cm skin incisions were made bilaterally in the subclavicular regions; immediately a loud hiss of escaping air was heard and the patient's condition improved rapidly. He was extubated after seven days and made a full recovery. Case 2. A 42-yr-old male was admitted to ITU three days after a street fight because of rapidly progressing SE, extending to the head, neck, chest, abdomen and legs. He was suffering from pneumomediastinum, pneumopericardium, and broken ribs, hyoid bone and Th10 spinous process. An emergency tracheostomy was performed and blow holes were made in both subclavicular regions. This resulted in rapid improvement and he was discharged home after two weeks in hospital. DISCUSSION AND CONCLUSION: Several methods of treatment for severe SE have been described, including pleural drainage, subcutaneous insertion of pig-tail drains, iv cannulas or large bore drains. The method described, albeit not always successful, is simple and can be applied in every setting.

[Congenital pseudocholinesterase deficiency]. / Wrodzony niedobór cholinesterazy osoczowej.

BACKGROUND: Congenital pseudocholinesterase (pChe) deficiency is a rare genetic abnormality which may lead to prolonged duration of action of muscle relaxants that are hydrolysed by pChe. We describe two cases in which mivacurium resulted in neuromuscular block lasting several hours. CASE REPORTS: Two non-related male patients, aged 26 and 7 years, scheduled for elective ENT surgery, received propofol, desflurane, remifentanil and mivacurium. At the end of the surgery it was not possible to reverse the neuromuscular blockade, and there were no responses to TOF or post-tetanic stimulation. Neuromuscular transmission returned spontaneously after 7, and 4 h, respectively. Postoperative assay revealed severe pChe deficiency in both patients, with values of 3393 UL(-1)and 2558 UL(-1), respectively (normal range 5100-11700 UL(-1). Family screening confirmed the presence of pChe deficiency in both cases. CONCLUSION: In any case of unexpected prolonged muscle relaxation after mivacurium, pChe deficiency should be considered and its activity measured.When confirmed, careful family screening is mandatory.

[Resuscitation decision in cases of hospital cardiac arrest--current practices and opinions of physicians]. / Decyzja o podejmowaniu resuscytacji w przypadku szpitalnego zatrzymania krazenia--aktualna praktyka i poglady lekarzy.

UNLABELLED: BACKGROUND; DNAR is the procedure when CPR is not undertaken as it appears to conflict with the patient's will or may not be in his or her best interests due to medical futility. DNAR decisions should be carefully discussed in advance by the medical team and patients and finally formally documented. DNAR orders are still extremely rare in Polish hospitals and decisions to forgo CPR are usually made at the very last moment. Therefore, we compare actual practice and opinions of physicians related to DNAR decisions. METHODS: The study, carried out during three consecutive months in a big university hospital, was based on two questionnaires. The first questionnaire explored actual practice regarding the decision to forgo CPR, whereas the second one--opinions about DNAR guidelines. The former was filled in by physicians involved in the "do not to attempt resuscitation" decision, the latter by the group of other physicians employed in the hospital. RESULTS: The survey was performed among 286 physicians filling in the first questionnaire and 200 physicians completing the second one. On-call doctors were prime decision makers (49%) with no input from the patient when the "do not attempt resuscitation" decision was made. Decisions to forgo resuscitation were usually informal and communicated to medical team orally (98%). However, 20% of physicians declare that patients should be involved in the decision-making process concerning CPR, and more then 30% respondents stress the need for collegial discussion. Nearly 80% of physicians believe that such formal decisions should be recorded in the patient's medical history. CONCLUSIONS: Current opinions of physicians regarding DNAR differ strikingly from clinical practice. Respondents highlighted the need for collegial discussions, the growing role of a patient in the decision-making process and importance of suitable documentation.

[Pandemic influenza A/H1N1v--guidelines for infection control from the perspective of Polish ITUs]. / Pandemia grypy A/H1N1v--wytyczne dotyczace kontroli zakazenia z perpektywy polskiego oddzialu intensywnej terapii.

In some countries, the influenza A/H1N1v pandemic, recently announced by WHO, was severe. Up to 10-30% of patients required ITU therapy due to rapidly increasing respiratory failure. In Poland, recommendations concerning the management of A/H1N1v infections, including those during ITU hospitalization, are vague and scattered. The WHO guidelines stress that the spread of infections should be limited by observance of personal hygiene rules, use of appropriate preventive measures and suitable administrative and technical actions. Only 30-60% of medical staff cleans their hands. Hand washing practices are inaccurate and too rare. Likewise, protective clothes and face masks are worn too rarely. FFP3 is believed to be the best mask in such cases, if properly used. Such masks should be individually adjusted, placed tightly over the face, without leaks around the edges. After use, masks and protective clothes should be considered as medical waste. Moreover, the guidelines for management of ITU patients diagnosed with A/H1N1v infections are extremely relevant in cases of other infections.

Fibreoptic intubation in awake patients.

BACKGROUND: Awake fibreoptic intubation has been recommended for adult patients with a difficult airway in whom anaesthesia and/or relaxation could lead to the "can not ventilate, can not intubate" situation. The paper describes three cases of elective awake intubations, as examples of our strategy in cases with a predicted difficult airway. CASE REPORTS: Three male patients with Mallampati scores 2, 3 and 3, scheduled for elective surgery, were premedicated with 7.5 mg oral midazolam and 0.5 mg iv atropine. With the patient on the operating table in the anti-Trendelenburg position, the upper airways were anaesthetized with 4 mL of topical 2% lidocaine, administered from a nebulizer via face mask. Additionally, the base of the tongue, nasal cavity and lower throat were sprayed with 10% lidocaine solution. Immediately before insertion of the bronchoscope, the patients received intravenously, 2 mg of midazolam and 0.05-0.1 µg kg-1 of fentanyl. A 5.2 mm/65 cm fibreoptic bronchoscope was inserted into the trachea and a reinforced endotracheal tube was slid down over it. Oxygen and additional doses of lidocaine were administered through the working channel of the scope. CONCLUSION: The described method is safe and effective, and can be recommended for cases where there is serious doubt about the possibility of maintaining an open airway during induction of anaesthesia, or in cases where intubation has failed during previous anaesthesia. Awake intubation is rarely associated with serious episodes of desaturation and it is usually well tolerated by motivated patients.

Awake fibreoptic intubation.

Awake fiberoptic intubation has been recommended for adult patients with a difficult airway in whom anaesthesia and/or relaxation could lead to the "cannnot ventilate, cannot intubate" situation. We describe the strategy and protocols of such management in cases with a predicted difficult airway. The described method is safe and effective, and can be recommended for cases where there is serious doubt about the possibility of maintaining an open airway during induction of anaesthesia, or in cases where intubation has failed during previous anaesthesia. Awake intubation is rarely associated with serious episodes of desaturation and it is usually well tolerated by motivated patients.

[Perforation of the internal jugular vein during cannulation for haemodialysis]. / Uszkodzenie zyly szyjnej wewnetrznej kaniula dializacyjna.

BACKGROUND: Reliable temporary vascular access is necessary for haemodialysis when the establishment of permanent access is not possible. Double-lumen catheters are favoured in most cases. These catheters are commonly inserted percutaneously using anatomic landmarks, but the technique is far from being perfect and serious complications may occur during the procedure. We describe a serious and potentially lethal complication of internal jugular venous cannulation. CASE REPORT: A 50-year-old woman was transferred from another hospital because of misplacement of a tunnelled permanent haemodialysis catheter and internal bleeding. A computed tomographic angiogram of the chest revealed that the catheter had migrated to the mediastinum. Emergency surgery with cardiopulmonary bypass was performed, the catheter removed, and the damaged left internal jugular and right subclavian veins were reconstructed. CONCLUSION: Migration of a dialysis catheter outside the vascular bed is a potentially lethal complication. Removal of a misplaced catheter may lead to massive uncontrolled bleeding and should be managed surgically.

[Preoperative anxiety assessed by questionnaires and patient declarations]. / Kwestionariuszowy i deklaratywny poziom leku chorych przed operacja.

BACKGROUND: The perioperative period can be anxiety-provoking for any patient scheduled for surgery. The anxiety can be divided into three categories: physiological, psychological and behavioural. For objective assessment, special questionnaires have been used, yet since they are too complicated for everyday use, simpler methods have been proposed. We have compared three measurements of anxiety to determine their equivalence in assessing anxiety before surgery: the State Trait Anxiety Inventory (STAI), the Visual Analogue Scale (VAS) and patient declaration in the form of an answer to a single question. METHODS: Thirty-eight ASA I and II adult patients, of both sexes, aged 18-60 years, and scheduled for elective abdominal or ENT surgery, were enrolled into the study. All patients were interviewed one day before the procedure and were asked to complete the STAI questionnaire, rate their fear on the VAS, and answer the question: "Are you afraid of anything?" The Kolmogorow-Smirnov test, t-Student test and r-Pearson correlation test were used for statistical analysis. RESULTS: Sixty six per cent of the questioned patients expressed a feeling of fear and their mean STAI-T (traid) score was 42.9 +/- 7.9, STAI-S (scale) 44.6 +/- 10.5. The VAS score was 3.7 +/- 2.6. Among those who did not declare a feeling of fear, the scores were: STAI-T: 36.9 +/- 8.2, STAI-S: 41.0 +/- 6.3, and VAS: 1.5 +/- 1.7. Females expressed a feeling of fear more often than males (p=0.03). There were no statistically significant differences related to age, the type of scheduled surgery or ASA score. The results obtained by all methods were closely correlated. CONCLUSION: We conclude that, since the results of anxiety measurement were comparable in all tests, a simple question or the VAS scale should be sufficient for proper assessment of preoperative anxiety.

[Cardiac arrest in chronic metabolic alkalosis due to sodium bicarbonate abuse]. / Zatrzymanie krazenia w przebiegu zasadowicy metabolicznej i zaburzen elektrolitowych u osoby spozywajacej sode oczyszczona.

BACKGROUND: Moderate metabolic alkalosis has not been considered as a life-threatening situation by many authors, but when it persists and pH increases above 7.65, the situation may become critical. CASE REPORT: We present a case of a 61-yr-old alcoholic male patient, who had been consuming approximately 200 g of sodium bicarbonate daily for twenty years, due to persisitent heartburn and abdominal pains. The patient was admitted to the ITU after home cardiac arrest and resuscitation. On admission he was unconscious and in respiratory distress, with a GCS of 5. Blood gases revealed that his pH was 7.64, HCO3 44 mmol L(-1), K+ 2.4 mmol L(-1)l, Cl- 44 mmol L(-1), and lactate concentration over 15 mmol L(-1). He was treated with controlled hypercapnia, up to a PaCO2 of 63 mm Hg, sedation, and administration of a large amount of chloride (864 mmol during the first day). The patient regained consciousness after 48 h, was extubated and transferred to the internal medicine department where he died 3 days later. DISCUSSION: Chronic alkali abuse can lead to various metabolic disturbances, neurologic disturbances and cardiovascular compromise. In the described case, the exact cause of cardiac arrest remained unknown, but may have been caused by alkalosis combined with hypoxia, hypokalemia and poor general condition. The extreme metabolic alkalosis (pH 7.8) could also have been enhanced by the administration of i.v. sodium bicarbonate during resuscitation. The treatment of choice in such cases should consist of vigorous chloride containing fluid resuscitation, ammonium chloride and hemodialysis.

The comparison of treatment results of type 1 diabetes mellitus complicated by end-stage diabetic nephropathy in patients undergoing simultaneous pancreas and pre-emptive kidney transplantation (SPPkTx) and patients enrolled into the dialysis program--a cohort study.

OBJECTIVE: A cohort study was conducted to compare treatment of patients with type 1 diabetes mellitus and end-stage diabetic nephropathy. PATIENTS AND METHODS: 47 type 1 diabetic patients required renal replacement therapy in years: 2001-2005 were enrolled. Simultaneous pancreas and preemptive kidney transplant (sppktx) was performed in 18 (group I). Group II consisted of 29 patients who entered dialysis program. Survival rate for patients from both groups was estimated. Transplanted organ function was evaluated for group II. Lipid profile and its correlation with thickness of carotid media was assessed. Impact of sppktx on diabetic retinopathy was investigated. Cost and life quality were compared between groups. RESULTS: Two-year cumulative recipient survival rate for group I and II was 100% and 96%, respectively. One-year cumulative survival rate for transplanted pancreas was 88% and for kidney grafts 94%. In group I cholesterol and triglyceride level before transplantation were: 207 +/- 38 mg/dl and 133 +/- 65 mg/dl and decreased after transplantation to 155 +/- 20 mg/dl and 78 +/- 25 mg/dl, respectively (p < 0.05). No difference of carotid media thickness was observed between groups. Stabilization of retinopathy was observed in 91.6% non-blind recipients. During the first year of the follow-up the costs of transplantation doubled those of dialysis therapy but in the second year the costs of dialysis exceeded the costs required for transplanted patients. CONCLUSION: Despite of major surgery and introduction of immunosuppression in group I, results did not differ significantly between groups during a two-year follow-up. After sppktx, stabilization of the carotid media was slower than the normalization of lipids. At the second year, transplantation is less expensive than dialysis.