Validation of a clinical assessment tool for spinal anaesthesia.

BACKGROUND: There is a need for a procedure-specific means of assessment of clinical performance in anaesthesia. The aim of this study was to devise a tool for assessing the performance of spinal anaesthesia, which has both content and construct validity. METHODS: The clinical assessment tool was generated using a focus group discussion of practicing anaesthetists. The tool comprised three components: a checklist of 11 pre-defined errors, two time intervals and a six-item global rating scale (GRS). Thirty-one anaesthetists at three different levels of experience underwent testing using the clinical assessment tool: novice (n=10), intermediate (n=10) and expert (n=11). RESULTS: The error checklist and GRS scores but not the time intervals were significantly different between the three groups (P<0.005). CONCLUSION: The error checklist and GRS form the basis for a procedure-specific assessment tool for spinal anaesthesia.

Direct effects of chemoradiotherapy following esophagectomy.

BACKGROUND: Esophageal cancer is a major cause of morbidity and mortality, but despite continuing research, few effective therapies have been identified. In recent years, surgical resection following chemoradiotherapy has been associated with improved survival in several clinical models. AIM: In a prospective, observational study, we evaluated the direct effects of chemoradiotherapy on postoperative mortality, morbidity, and inflammatory response in patients following esophagectomy. METHODS: The study cohort was divided into two groups: the first group received preoperative chemoradiotherapy, while the second group had surgical intervention without prior treatment. Nutritional status was evaluated for the members of both patient groups at various time points. RESULTS: Preoperative chemoradiotherapy did not influence morbidity or organ function, and the postoperative inflammatory response did not show immunosuppressive side effects directly after surgery. CONCLUSION: Preoperative chemoradiotherapy does not improve postoperative organ function, inflammatory response or nutritional status in the patients. These findings may help to improve outcome in patients with esophageal cancer in the future.

Hungarian web-based nationwide anaesthesia and intensive care data collection and reporting system: its development and experience from the first 5 yr.

BACKGROUND: Annual data collection is obligatory in Hungary for every department in the fields of anaesthesia and intensive care. A new, web-based data-reporting system was introduced in Hungary in 2003. The present paper summarizes experience from the first 5 yr of its operation. METHODS: The Information Technology Working Group of Hungarian Society of Anaesthesia and Intensive Care developed a data collection system, which was Internet-based, provided web surface for every accredited department, and used the integration of international code systems. The analysis mode summarized the data automatically at loco-regional, national, or both levels. In 2008, a questionnaire was sent to the users in order to evaluate the usefulness of, and user satisfaction with, the web-based system. RESULTS: The examples of anaesthetic and intensive therapy workload activities reflect the status of the discipline in Hungary. There have been no significant changes in the total number of anaesthesias per year in the past 5 yr, except that the number of combined general and regional anaesthesias has been elevated by more than 30%. The physicians' workload has increased by 13.2% in relation to the total number of anaesthetic procedures per physician per year. In this field, our data have verified that the number of physicians has decreased in Hungary. On the basis of the opinion of the users, the web-based data collection system has increased the effectiveness and accuracy of annual data collection. CONCLUSIONS: The developed web-based system is an effective tool for data collection. Its usefulness was also borne out by its users on the basis of experience from the first 5 yr.

Effect of glutamine in patients with esophagus resection.

UNLABELLED: Glutamine is the most abundant amino-acid in the extra- and intracellular compartments of the human body, which accounts for over 50% of its free amino-acid content. Utilization of glutamine peptides is explicitly useful, resulting in a decrease in the number of postoperative infectious complications, period of hospitalization, and therapeutic costs. This article aims to study the effects of glutamine on systemic inflammatory response, morbidity, and mortality after esophagectomy. A prospective, randomized, double-blind, and controlled trial was used. Following sealed-envelope block randomization, the patients were divided into two groups. Members of the glutamine group (group G) received glutamine (Dipeptiven, Fresenius) as continuous infusion for 6 hours at 0.5 g/kg for 3 days prior to, and 7 days following surgery; while patients of the control group were given placebo. We examined 30 patients in group G, and 25 patients as controls. In both patient groups, the levels of total protein, albumin, pre-albumin, retinol binding protein, transferrin, transferring-saturation, C-reactive protein, procalcitonin, lymphocte, Interleukin-6, Interleukin-8, tumor necrosis factor alpha, and serum lactate were determined prior to surgery (t(0)), directly after surgery (t(u)), following surgery on day 1 (t(1)), day 2 (t(2)), and day 7 (t(7)). For statistical analysis Mann-Whitney U test and chi-square test were used. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Intensive care unit morbidity and mortality was similar in both groups (group G: 24 survivors/6 nonsurvivors; CONTROL: 17 survivors/8 nonsurvivors; P= 0.607). Daily Multiple Organ Dysfunction Score did not differ significantly between the two groups. The observed inflammatory markers followed the pattern we described without significant difference. Based on our study, the glutamine supplementation that we used had no influence on morbidity, mortality, or postoperative inflammatory response after esophagectomy.

Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation.

BACKGROUND: A number of target points have been used for fluid replacement in severely burned patients. The aim of our prospective randomized study was to compare the effect of two different types of fluid resuscitation regimes on the multiple organ dysfunction score (MODS) and central venous oxygen saturation (ScvO(2)) in the first 3 days after injury. METHODS: Twenty-four patients admitted to the critical care unit of a university hospital with the presence of burn injury affecting more than 15% of the body surface area and in-hospital fluid resuscitation started within 3 h after burn injury were included. Patients were randomized into two groups. Fluid resuscitation was guided by the hourly urine output (HUO Group, n=12) or by the intrathoracic blood volume index (ITBVI Group, n=12). Invasive transpulmonary hemodynamic measurements utilizing pulse contour analysis with a single dilution technique and continuous ScvO(2) measurements were performed in both groups. RESULTS: The mean ScvO(2) was significantly lower in the HUO Group than in the ITBVI Group (P=0.024) for the first 24 h. MODS was significantly higher in the HUO Group than in the ITBVI group 48 h (P=0.024) and 72 h after injury (P=0.014). The two main outcome parameters, i.e., MODS calculated at 48 and 72 h after injury and ScvO(2) were negatively correlated on day 1 (r=-0.684, P=0.004, r=-0.677, P=0.003). There were no statistical differences in clinical outcome parameters. CONCLUSION: Our data suggest that ITBVI may be a better target parameter than HOU in the fluid resuscitation of severely burned patients after injury.

Short-term effects of N-acetylcysteine and ischemic preconditioning in a canine model of hepatic ischemia-reperfusion injury.

AIMS: We evaluated the possibility that repeated ischemic preconditioning or N-acetylcysteine (NAC) could prevent ischemia-reperfusion injury as determined by indocyanine green plasma disappearance rate (ICG-PDR) or has favorable hemodynamic effects during reperfusion in an in vivo canine liver model. METHODS: Under general anesthesia, 3 groups of mongrel dogs (n = 5 per group) were subjected to (1) 60-min hepatic ischemia, (2) same ischemia preceded by intravenous administration of 150 mg kg(-1) NAC, and (3) three episodes of IPC (10-min ischemia followed by 10-min reperfusion) prior to same ischemia. Hepatic reperfusion was maintained for a further 180 min, with hemodynamic and hepatic function parameters monitored throughout. RESULTS: Plasma disappearance rate of indocyanine green and serum levels of aspartate transferase and alanine transferase showed no significant differences between groups. Although liver injury was obvious, reflected by hemodynamic, blood gas, and liver function tests, NAC and IPC failed to prevent decay in hepatic function in this canine model. CONCLUSION: The results do not support the hypothesis that short-term use of NAC and IPC is beneficial in hepatic surgery.

Low hematocrit per blood viscosity ratio as a mortality risk factor in coronary heart disease.

Increased blood viscosity has not been associated with mortality risk in coronary heart disease (CHD). We aimed to investigate the predictive power of hematocrit per blood viscosity (Hct/BV) ratio as a marker of rheological oxygen carrying capacity of the blood to assess mortality risk of CHD. Elective coronary angiography was performed and CHD was proved in 109 patients in 1996 and 1997. In 78 cases (72%) complete follow up information was obtained in February 2006. During the follow up time (mean 8.9 years) 10 patients died due to cardiac cause (group C). Two patients died due to non-cardiac cause and 66 were still alive at the end of the follow up period (group NC, n=68). Mean hematocrit per blood viscosity (Hct/BV) ratio was significantly lower in group C comparing to NC (87+/-5; 93+/-9 Pa(-1)s(-1), SD, respectively, p=0.022). Other factors (body mass index, serum cholesterol, fibrinogen, hematocrit, plasma and blood viscosity, cardiac index, left ventricular ejection fraction) provided no statistical differences. Kaplan-Meier survival analysis showed only the impact of fibrinogen and Hct/BV ratio on cardiac mortality (p=0.029 and 0.009, respectively). Receiver operating characteristic curves proved only Hct/BV ratio to be able to differentiate between groups (area under curve: 0.716, p=0.028). Hct/BV ratio showed significant negative correlation with the frequency of hospital admissions (r=-0.377, p=0.03). Low Hct/BV ratio can be regarded as a risk factor of cardiac death in CHD.

Sedimentation characteristics of leucocytes can predict bacteraemia in critical care patients.

BACKGROUND: Early detection of blood stream infection can be lifesaving, but the results of blood cultures are not usually available before 24 hours after blood sampling. An earlier indication would lead to the initiation of immediate and adequate antibiotic treatment with obvious advantages for the patient. OBJECTIVE: To evaluate the ability of leucocyte count, serum procalcitonin (PCT) concentration, erythrocyte sedimentation rate (ESR), and leucocyte antisedimentation rate (LAR) in predicting the blood culture results in critical care patients. METHODS: 39 consecutive patients with their first febrile episode were investigated prospectively. LAR was determined as the percentage of leucocytes crossing the midline of a blood column upward during one hour of gravity sedimentation. The relevance of the different variables was estimated by likelihood ratio tests and area under receiver operating characteristic curves (AUC). RESULTS: 23 patients had positive blood culture results and 16 negative. LAR was significantly higher in bacteraemic patients than in non-bacteraemic patients (p = 0.001), but leucocyte count, ESR and PCT level failed to show significant differences. Leucocyte count, PCT, and ESR yielded low discriminative values with the AUCs of 0.66, 0.64, and 0.52, respectively. LAR provided a likelihood ratio of 3.6 and an AUC of 0.80 (95% confidence interval, 0.64 to 0.95) (p = 0.002). CONCLUSIONS: The simple LAR test can predict blood culture results and support urgent treatment decisions in critical care patients in their first febrile episode.

Gravity sedimentation of leukocytes is partially independent from erythrocyte sedimentation.

Leukocyte function tests are suitable for monitoring the severity of chronic inflammatory and acute infectious diseases. The tests usually require time consuming leukocyte separation techniques while the original character of leukocytes can substantially alter. In contrast, we noted that gravity sedimentation properties of leukocytes is simple to measure and it also reflects non-specific inflammatory reactions of leukocytes. Our novel test is named leukocyte antisedimentation rate (LAR) which is measured by leukocyte counting in the upper (U) and lower (L) half of the sedimentation blood column after one-hour gravity sedimentation of the whole blood. The formula LAR=100.(U-L)/(U+L) is used to calculate the percentage of leukocytes crosses the middle line of sedimentation blood column upward during one-hour sedimentation (normal range<15%, inter-assay coefficient of variation<5%). In this study we found that in vitro pre-treatment of septic patients' blood samples with protamine, lidocaine and prednisolone decreased leukocyte antisedimentation rate in a concentration dependent manner without effecting erythrocyte sedimentation rate. Leukocyte adherence was measured by the retention rate of leukocytes in a nylon fibre column. There was a significant positive correlation between leukocyte antisedimentation rate and leukocyte adherence (p<0.01), hematocrit (p<0.05), erythrocyte sedimentation rate (p<0.05) when blood samples of 35 healthy individuals were analysed. We concluded that leukocyte antisedimentation rate in septic patients is significantly elevated comparing to healthy controls and as a bedside test it can reflect leukocyte involvement in infections. In vitro protamine, lidocaine and prednisolone pre-treatment of septic patients' blood samples indicates that leukocyte antisedimentation process is partially independent from the ongoing erythrocyte sedimentation.

Gender differences in hemorheological parameters of coronary artery disease patients.

Plasma fibrinogen concentration, plasma and whole blood viscosity (WBV) are independent risk factors of coronary artery disease (CAD). Fibrinogen seems to be a relatively stronger risk factor for women than for men, but men are more endangered by higher hematocrit (Hct) and WBV than women are. We have previously reported that a theoretically optimal Hct value can be determined using Hct/WBV ratio in healthy subjects, hyperlipidemic and Raynaud's disease patients. Our aim was to examine whether Hct/WBV ratio is differently correlated with Hct in men and women with proven CAD. In a retrospective study we analysed the hemorheological data of 162 CAD outpatients (107 men and 55 women). Coronary angiography, echocardiography and impedance cardiography were performed. Hemorheological parameters (Hct, fibrinogen level, plasma viscosity, WBV), blood picture, serum lipid concentrations were determined and Hct/WBV ratio was calculated. Mean ages of male and female patients were similar (54.9 and 55.4 years, respectively), but men had significantly higher coronary angiography score than women. Mean left ventricular ejection fraction, stroke volume index and cardiac index showed no significant differences in men and women. Similarly, lipid concentrations, fibrinogen levels and plasma viscosities demonstrated no statistical differences. However, Hct, WBV and Hct/WBV ratios were significantly higher in male than in female patients (p < 0.00001; p < 0.00001 and p < 0.005, respectively). The most striking gender difference was found in the correlation between Hct/WBV ratio and cardiac index. Men older than 56 years showed negative, women positive correlation (r = -0.485, p = 0.01; r = 0.468, p = 0.006, respectively). This study demonstrates that Hct/WBV ratio as a rheological oxygen carrying capacity parameter is positively correlated with the cardiac index as it can be expected. However, the correlation is negative in elder men indicating an unhealthy relation between hemodynamic and hemorheologic parameters.

A new simplified assay for evaluation of motile activity of human polymorphonuclear leucocytes.

We studied the adaptation of a filtration instrument to an assay for cell migration experiments. The commercially available Nuclepore filter holders were modified so that isolated human polymorphonuclear leucocytes (PMNs) were allowed to penetrate a porous filter membrane and to enter a compartment under the membrane. The total number of PMNs which had passed the pores during an hour of incubation could be counted. In this way we carried out experiments using Shigella sonnei lipopolysaccharide and dilutions of E. coli culture supernatant as chemoattractants for healthy human PMNs. These studies showed that the method can distinguish between random and directed movements of PMNs and it is sensitive to the concentrations of chemoattractant. Furthermore, the data obtained using PMNs from the same subject on different days seem to be comparable.

Initial filtration rate and initial clogging in the Hemorheometre.

The role of different factors contributing to red cell filterability in the Hemorheometre has been investigated. Although the original method uses a small volume of suspension to determine red cell filterability, the present experiments showed that the results obtained are still significantly affected by filter clogging. Consequently a change in filterability could be due to a change in filter clogging possibly by residual leucocytes. An adaptation of filter chamber and filling method is described, resulting in a simpler and faster measuring procedure. The inaccuracy in measuring low haematocrits contributes significantly to experimental errors. Therefore a definition of red cell filterability based on the red cell count (instead of haematocrit) of the suspension is suggested.

Hemorheology and hypertension: not "chicken or egg" but two chickens from similar eggs.

A number of clinical studies have demonstrated significant positive correlation between the severity of arterial hypertension (AHT) and whole blood viscosity. Red blood cell aggregation has also been associated with AHT especially in the severe form of the disease. The main possible cause of increased red blood cell aggregation is fibrinogen which can be found in a significantly higher concentration in patients with AHT than in healthy controls. On the other hand, blood pressure reduction with angiotensin-converting-enzyme inhibitors, calcium-channel-blocking agents, beta or alpha-receptor blocking drugs leads to a significant improvement of blood rheology. It can be presumed that abnormal hemorheology and AHT are not directly linked but they share the same inductive genetic and/or environmental factors like obesity, chronic mental stress, physical inactivity and cigarette smoking. Regarding this hypothesis, the appropriate question is not whether hemorheological factors are causes or results of AHT but what their common origins are. Further studies are needed to clarify this hypothetical link between hemorheology and AHT.

Leukocyte flotation during gravity sedimentation of the whole blood.

The original Westergren blood sedimentation technique was modified to assess leukocyte sedimentation properties. The relative change of leukocyte and erythrocyte counts was measured in the upper half section of blood column in vertically positioned sedimentation tubes in 10-minute-intervals for 60 minutes. During the first 20 minutes of gravity sedimentation, the leukocytes taken from critically ill patients showed upward flotation, however, healthy individuals' leukocytes demonstrated slight sedimentation. The upward flotation rate of leukocytes seemed less dependent on erythrocyte sedimentation during the first 15 minutes of sedimentation time than after it. Based on this observation, the sedimentation properties of leukocytes were characterized by the leukocyte antisedimentation rate taken at the 15th minute of sedimentation time (LAR15). Erythrocyte aggregability index, plasma fibrinogen concentration and native leukocyte count did not correlate to LAR15 in healthy volunteers (n = 25). However, LAR15 was correlated to leukocyte adherence (p < 0.01), to whole blood viscosity (p < 0.05), to hematocrit (p < 0.05) and to the conventional erythrocyte sedimentation rate (p < 0.05).

Characteristics of light and heavy polymorphonuclear leukocytes.

Whole blood gravity sedimentation technique can be modified for studying leukocyte sedimentation properties. Previously, we demonstrated that the displacement rate of leukocytes was associated with activation of leukocytes during traditional gravity sedimentation of the whole blood. The plasma flow as well as the difference between the specific gravity of leukocytes and plasma propel the leukocytes upward in the sedimentation tube while the erythrocyte aggregates are descending. The leukocyte ascension rate can be described as the increment of leukocyte concentration in the upper half section of the blood column after one-hour sedimentation. The aim of the present study was to characterize the ascending and non-ascending leukocytes using a flow cytometric technique. Venous blood samples were taken from 8 healthy controls and 8 septic patients after major thoracic or abdominal surgical procedures. The upper and lower halves sections of venous blood column were separately removed from the sedimentation tube after one hour gravity sedimentation. Using flow cytometry, the leukocyte subsets were identified by their CD45 density and side scatter parameters followed by characterization of their cellular size and cytoplasmic granularity. The size indices of septic patients' ascending polymorphonuclear leukocytes (PMNs) were significantly lower than that of the non-ascending ones (253 +/- 22 versus 387 +/- 12 (SEM), p < 0.002) or the ascending PMN fraction taken from healthy individuals (382 +/- 28, p < 0.005). Septic patients' ascending PMNs presented significantly lower cytoplasmic granularity indices compared to non-ascending (447 +/- 23 versus 538 +/- 18, p < 0.05) or healthy ascending PMNs (539 +/- 20, p < 0.05). The cellular size and cytoplasmic granularity indices of heavy and light monocytes as well as lymphocytes were similar in both groups. It can be assumed that venous blood samples of septic patients contain significantly smaller PMNs with less cytoplasmic granularity than healthy control cells.

The effect of RheothRx Injection on the hemorheological parameters in patients with acute myocardial infarction.

This study evaluated the hemorheological effects of a nonionic block copolymer surfactant, RheothRx Injection, on the hemorheological parameters in patients with acute myocardial infarction (AMI). For the in vitro study blood from 24 patients admitted with chest pains (mean age: 49 +/- 11 yrs) was sampled after admission and in AMI cases (15 patients, mean age: 53 +/- 13 yrs) a second sample was collected 48 hours later. Different concentrations of RheothRx were added (0.25, 0.5, 1, 2 and 5 mg/ml) and the blood was tested for RBC aggregation via our computerized Myrenne Aggregometer (at Hct = 40%). Besides other routine laboratory parameters, fibrinogen levels were measured. In a substudy for CORE Trial, the hemorheological effects of RheothRx infusion was studied. Seven patients (mean age: 63 +/- 13 yrs) admitted with AMI and randomized for CORE Trial were studied. The samples were collected after admission, at 12, 24, 48 hours, and at day 8 and 35. In vitro we found a significant (p < 0.05 or better) concentration-related decrease of RBC aggregation from 0.5 mg/ml drug concentration in the admission (both groups) and in the 48 hour (AMI) samples, in AMI patients with a mean decrease of 7 and 5% at 0.5 mg/ml, 13 and 8% at 1 mg/ml, 22 and 19% at 2 mg/ml and 39 and 33% at 5 mg/ml plasma concentration of the drug. In the CORE Trial patients hemorheological parameters (plasma and whole blood viscosity, RBC aggregation and fibrinogen level) decreased during and after the administration of RheothRx, but after 2-8 days their values returned to the baseline level. These findings indicate that this agent can significantly reduce RBC aggregation and other hemorheological parameters, and thus suggest its potential usefulness in clinical states associated with increased RBC aggregation.

[Analysis of the function of the circulatory system and its components based on rheologic viewpoints]. / A keringési rendszer és alkotó részei müködésének elemzése haemorheologiai szempontok alapján.

The authors analyse from hemorheological viewpoint the vascular system and the blood, its special circulating medium. The most important anatomical and physiological characteristics are referred to completing them with the presentation of the basic rheophysical parameters and correlations. Factors determining the viscosity of blood are specified and discussed separately. The definition based on literary data according to which the viscosity of blood is greater with lower circulation gradient and lower--in view of the non-Newtonian character of bloodat a higher rate is discussed. The significance of the adaptability of blood cells is emphasized in the determination of the rheological characteristics of blood.

[The roots, concept, subject, and history of hemorheology, current tasks and further perspectives]. / A haemorheologia gyökerei, fogalma, tárgya, története, mai feladatok és további perspektívák.

The authors give a reviewing summary on the origin of hemorrheology and its relationship to basic sciences. Its concept is defined, recognitions and endeavours of this character in the history are analysed and followed up. The names of the scientists whose merit was significant in the creation of rheology-hemorrheology are presented referring briefly to the main points of their activity. The general, international situation of the discipline is outlined, countries leading and determining its development are indicated and the main points of the situation in Hungary are described. The examinational fields of clinical hemorrheology are presented, describing briefly the future directions.

[Leukocyte migration during erythrocyte sedimentation]. / Leukocyták mozgása vörösvértest-süllyedés folyamán.

Sedimentation properties of leukocytes was measured with a new, simple and reproducible method. The increment of leukocyte concentration was determined in the upper 100 mm section of the sedimentation blood column after one hour gravity sedimentation of the whole blood. The result (leukocyte antisedimentation rate, LAR) was expressed in percentage of the original, presedimentation leukocyte concentration. Blood samples taken from 35 healthy adults were investigated and 12.5% and 17.4% increments were found in total leukocyte count and in granulocyte concentration respectively in the upper half of the sedimentation blood column. The mean coefficient of variation of LAR measurements was 3.2% LAR was found significantly higher in a mixed group of patients than in healthy controls. The sedimentation properties of leukocytes were in significant correlation with leukocyte adherence (p < 0.01), with whole blood viscosity, hematocrit, and erythrocyte sedimentation rate (each p < 0.05) when blood samples of healthy individuals and postoperative intensive care patients were analysed in combination. In vitro pre-treatment of patients' blood samples with prednisolone and lidocaine resulted in a significant diminishment of LAR in a concentration dependent manner.

[Analysis of costs of drug therapy in patients with acute respiratory insufficiency]. / Az akut légzési elégtelenség kezelésének gyógyszerköltség-elemzése.

In a retrospective study, the authors analysed the clinical data of 38 patients who were admitted to a surgical intensive care unit (SICU) for mechanical ventilation lasted for at least 72 hours. The APACHE III score was calculated on the basis of clinical data documented during the first 24 hour of the treatment and the cost of drug administrations per patients per day was also determined by analysing all the drugs prescribed on the first 5 days of intensive care. The patients admitted to SICU with polytrauma or with abdominal septic focus required significantly higher cost of drug treatment than the patients after cardiopulmonary resuscitation or with bronchial asthma or pneumonia. The APACHE III score of the patients died at the SICU was significantly higher compared to the survivors who needed more expensive drug therapy than the non-survivors required. Antibiotic treatment, blood transfusions, and human plasma proteins caused the highest drug expenditure. There was no significant correlation between the APACHE III score and the cost of drug treatment.