[New definition of ventilator associated pneumonia might not necessarily have been a step in the right direction. Key takeaways from published studies after two years in clinical use]. / Czy nowa definicja zapalenia pluc zwiazanego z wentylacja mechaniczna spelnila swoje zadanie? Wnioski z pierwszych doniesien po dwóch latach zastosowania w klinice.

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections. VAP is associated with prolonged hospitalization and visibly increased mortality, which in the group of patients with VAP ranges from 25% to 47%. In January 2013 Centers of Disease Control and Prevention introduced a new definition for VAP. Subjective criteria in the previous VAP definition were the reason for difficulties in VAP surveillance and assessment of efficacy of ventilator bundles and other quality improvement initiatives. The purpose of this article is to summarise the new definition of VAP and the first researches after two years of use of the new definition. The new definition of ventilator-associated events (VAE) identifies a broader group of patients than the previous VAP definition. Surveillance of all complications of mechanical ventilation aimed to create more efficient prophylaxis bundles and to decrease the mortality in critically ill patients. The latest published studies suggest that most of the complications defined as VAE are patient-related, not modifiable risk factors and these patients had no evidence of hospital-acquired complications. The new definition failed to detect many patients with VAP and it has not resolved the ambiguities related to the diagnosis of this complication. It seems that the new surveillance program will not lead to introducing new prevention strategies that could decrease the mortality in intensive care unit patients.

[Anesthesia for cesarean section in patients with preexisting neurologic diseases--10 years of practice]. / Znieczulenie do ciecia cesarskiego u pacjentek z choroba neurologiczna--10 lat doswiadczen.

OBJECTIVES: Regional anesthesia is considered a 'gold standard' for cesarean sections. However, it is very often contraindicated in patients with coexistent neurological diseases. This article attempts to review the specific concerns for administration of anesthesia for cesarean section posed by spinal diseases, epilepsy sclerosis multiplex and others. MATERIALS AND METHODS: We present 85 cases of parturients with pre-existing neurological diseases, who received anesthesia for caesarean section at the First Clinic of Anesthesia and Intensive Care in the last 10 years. We compared those cases with the medical literature. RESULTS: We successfully used general as well as regional anesthesia. The decision about the anesthetic technique was based on the neurological state of each patient. CONCLUSION: No guidelines for anesthesiologist concerning the best anesthetic technique for patients with neurological diseases have been designed so far. The choice of the safest method is made individually and depends on a variety of factors.

Bioequivalence and pharmacokinetics of two 10-mg bisoprolol formulations as film-coated tablets in healthy white volunteers: a randomized, crossover, open-label, 2-period, single-dose, fasting study.

OBJECTIVE: The aim of the study was to investigate the bioavailability of a generic formulation of 10-mg bisoprolol film coated tablets (test) as compared to that of a branded formulation (reference) at the same strength to determine bioequivalence and to apply for regulatory approval. The secondary objective of the study was to evaluate tolerability of both formulations. METHODS: A randomized, crossover, open-label, 2-period, single-dose, comparative study was conducted in healthy white volunteers in fasting conditions. A single oral dose administration of the test or reference formulation was followed by a 14-day wash-out period. Blood samples were collected up to 60 hours after dosing. The bisoprolol concentrations in plasma samples were determined using a validated LC-MS/MS method. The formulations were considered bioequivalent if 90% CI of geometric mean ratios (test/reference) for AUC0-t, AUC0-∞ and Cmax were within the range 80.00 - 25.00%. Adverse events were monitored throughout the study based on the clinical parameters and volunteer reports. RESULTS: Healthy male and female subjects participating in the study had a median (range) age of 23 (20 - 43), weight of 68 kg (52 - 84), height of 172 cm (157 - 184), and BMI of 23.1 kg/m2 (19.3 - 24.9). The 26 consented volunteers have been included and 24 of them completed the clinical part of the study. The geometric mean test/referenceratios (90% CI) for AUC0-t, AUC0-∞ and Cmax were 104.12% (100.52 - 107.85%), 104.05% (100.49 - 107.75%) and 107.91% (103.04 - 112.99%), respectively. All 90% CI were embraced by the 80.00 - 25.00% acceptance interval. No serious adverse events were reported. A total number of 6 non-serious, moderate adverse events were registered, including headache and vomiting in one subject. CONCLUSIONS: The results of the single-dose study in healthy white volunteers indicated that the film-coated tablets of Bisocard® 10 mg manufactured by ICN Polfa Rzeszów S.A. (test formulation) are bioequivalent to those of Concor 10® manufactured by Merck KGaA (reference formulation). Both formulations were well tolerated.

Bioequivalence study of 2.5 mg film-coated bisoprolol tablets in healthy volunteers.

BACKGROUND: Bisoprolol is one of the most widely used beta-blockers characterised by cardioselectivity, and it has no intrinsic sympathomimetic activity. It is commonly used in the treatment of coronary heart disease and heart failure. AIM: The aim of study was to assess the bioequivalence of the film-coated tablets containing 2.5 mg of bisoprolol (Bisocard® - the medicinal product) to the original medicinal product (Concor Cor 2.5® - the reference). METHODS: A randomised, open-label, two-period, crossover, single-dose, relative bioavailability study was conducted in fasted healthy Caucasian volunteers. A single 10-mg oral dose (four tablets of 2.5 mg) of the test or reference product was followed by a 14-day wash-out period, after which the subjects received the alternative product. Blood was sampled within a period of 60 h post administration in pre-specified time points. Bisoprolol concentrations were determined by a validated LC-MS/MS method. The products were considered bioequivalent if the 90% confidence interval (CI) of the log-transformed geometric mean ratios (test vs. reference) for AUC(0-t), AUC(0-∞), and Cmax were within 80-125% limits. Adverse events were monitored during the study based on the subject claims and clinical parameters. RESULTS: Twenty-six healthy male and female volunteers (mean age ca. 29 years; body mass index 22.7 kg/m²) were in-cluded in the study, and 24 completed the clinical part. The geometric mean ratios (test/reference) for the log-transformed AUC(0-t), AUC(0-∞), and Cmax were 95.16% (90% CI 92.52-97.87%), 95.08% (90% CI 92.40-97.83%), and 100.00% (90% CI 94.83-105.45%), respectively. There were no significant differences in the pharmacokinetic parameters between the test and reference formulations. No serious adverse events were reported. CONCLUSIONS: The results of this single-dose study in healthy Caucasian volunteers indicate that Bisocard®; 2.5 mg film-coated tablets are bioequivalent to the reference product - Concor Cor 2.5®; 2.5 mg film-coated tablets. Both products had similar safety profile and have been well tolerated.

Comparison of the techniques for the identification of the epidural space using the loss-of-resistance technique or an automated syringe - results of a randomized double-blind study.

BACKGROUND: The conventional, loss of resistance technique for identification of the epidural space is highly dependent on the anaesthetist's personal experience and is susceptible to technical errors. Therefore, an alternative, automated technique was devised to overcome the drawbacks of the traditional method. The aim of the study was to compare the efficacy of epidural space identification and the complication rate between the two groups - the automatic syringe and conventional loss of resistance methods. METHODS: 47 patients scheduled for orthopaedic and gynaecology procedures under epidural anaesthesia were enrolled into the study. The number of attempts, ease of epidural space identification, complication rate and the patients' acceptance regarding the two techniques were evaluated. RESULTS: The majority of blocks were performed by trainee anaesthetists (91.5%). No statistical difference was found between the number of needle insertion attempts (1 vs. 2), the efficacy of epidural anaesthesia or the number of complications between the groups. The ease of epidural space identification, as assessed by an anaesthetist, was significantly better (P = 0.011) in the automated group (87.5% vs. 52.4%). A similar number of patients (92% vs. 94%) in both groups stated they would accept epidural anaesthesia in the future. CONCLUSION: The automated and loss of resistance methods of epidural space identification were proved to be equivalent in terms of efficacy and safety. Since the use of the automated technique may facilitate epidural space identification, it may be regarded as useful technique for anaesthetists inexperienced in epidural anaesthesia, or for trainees.

Coma in the course of severe poisoning after consumption of red fly agaric (Amanita muscaria).

Red fly agaric poisoning is rare. It can be consumed for suicidal purposes or its psychedelic effect. The paper describes the case of a young men, who fell into a coma after ingestion of the red toadstools. Quick identification of the poison, early use of gastric lavage and symptomatic treatment resulted in regression of symptoms and lead to the patient's discharge from the hospital on the third day after intoxication. Authors discussing the poisonous alkaloids contained in the red toadtools: ibotenic acid, muscimol, muscasone and muscarine and theirs properties, responsible for the symptoms of intoxication.

Anatomical landmarks based assessment of intravertebral space level for lumbar puncture is misleading in more than 30%.

BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. METHODS: Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting-up' approach starting with the L5-1 space was applied. RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences fund in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. CONCLUSIONS: The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

The substantial impact of ultrasound-guided regional anaesthesia on the clinical practice of peripheral nerve blocks.

BACKGROUND: Ultrasound-guided (US-guided) regional anaesthesia has gained worldwide popularity in recent years owing to the benefits the method offers to patients. The 1st Department of Anaesthesiology and Intensive Care of Warsaw Medical University was one of the first centres in Poland to employ US-guided peripheral nerve blocks (PNB) on a routine basis. The technique was incorporated into the institution's clinical practice from 2007. The purpose of this study was to retrospectively assess changes in the clinical practice of US-guided versus non US-guided PNBs over six years of experience with the technique. METHODS: Retrospective analysis assessing the prevalence of PNB methods, local anaesthetic (LA) injection techniques (i.e. single injection vs. multiple), LA volumes used, success rates and the incidence of complications. RESULTS: This study included 4,066 PNBs performed between January 2006 and June 2012. The results showed systematic growth in the prevalence of US-guided blocks in the total number of PNBs, from 8.6% in 2007 up to 53.3% in 2012. The mean LA volume used in PNB was significantly lower in US-guided blocks compared to traditional PNB techniques (respectively, 21.83 mL vs. 31.41 mL, P < 0.05) without a decrease in the success rate (respectively, 76% vs. 74%, P > 0.05). A shift in the prevailing block technique from single injection to multiple injections was observed, regardless of the nerve location technique employed (from 29% up to 84% of PNBs performed using multiple injection technique). CONCLUSIONS: The use of ultrasound optimizes the technique of peripheral blocks and the amount of local anaesthetic used. Ultrasonography does not affect the safety of peripheral blocks.

Over 500 obturator nerve blocks in the lithotomy position during transurethral resection of bladder tumor.

INTRODUCTION AND AIM OF THE STUDY: Spinal anesthesia for transurethral resection of bladder tumor (TURB) does not prevent unintended stimulation of the obturator nerve when electroresection is performed on the lateral wall of the bladder. It results in muscle contraction of the adductor muscles of the thigh, which may lead to perforation of bladder wall with the resectoscope loop. The aim of the study was to assess the efficacy and safety of obturator nerve block (ONB). METHODS: This prospective study was conducted between 01/01/1999 and 12/31/2010 in the Department of General, Oncologic and Functional Urology, Medical University of Warsaw. In 431 patients undergoing TURB adductor spasms were observed. In these cases nerve stimulation and ONB with 2% lidocaine using thigh interadductor approach in the lithotomy position were performed. RESULTS: The efficacy of 542 ONB was 94%. In 31 cases general anesthesia was necessary. There were two cases of urinary bladder perforation, but only one resulted from an insufficient nerve block. Both were managed conservatively. Neither hematomas nor neurological adverse events were observed. CONCLUSION: The described method offers a high rate of efficacy and ensures optimal and safe conditions for the resection of a tumor located on the inferolateral wall of the urinary bladder. The risk of complication is low.

Multiple organ failure after a fall from heights complicated by cardiac rupture and subacute cardiac tamponade.

Accidents and posttraumatic injuries are one of the most important health and social problems. Most of them require immediate medico-surgical intervention. Accidents are the leading cause of death among young people under age of 40. In 25% of cases they lead to disability. Fall from height causes inter alia blunt chest trauma, and internal organs contusion (e.g. heart and lungs), and may be fatal to substantial number of trauma victims. Excluding criminal injuries, this kind of trauma may occur during accidental fall or deliberate suicide attempt. Paper describes polytrauma victim who fell down from the eight floor (suicide attempt). Subacute pericardial tamponade, caused by cardiac wall rupture,occurred several hours after accident. The patient survived politrauma with severe cardiac injury complication thanks to effective multidisciplinary and multistage surgical treatment.

Unexpected fatal right ventricular rupture during liver transplantation: case report.

BACKGROUND: The pulmonary artery catheter provides most hemodynamic informations, which are necessary for the patient monitoring during liver transplantation. However, its application may be associated with complications. CASE REPORT: Authors present a case of unexpected right ventricular rupture during liver transplantation in a 53-year-old male, with end-stage liver disease secondary to hepatitis C virus and alcohol abuse. The most likely cause of this complication was myocardial scarification of right ventricle during introducer sheath inserting. There was six hours period between vessel cannulation and the first signs of heart failure, which occurred in the final anhepatic phase. Attempts to surgical repair of damaged heart wall failed and the patient died. CONCLUSIONS: Based on the present case analysis we suggest to restrict the introduction depth of dilatator and possibly shorten it 2-3 cm by the manufacturer. We should also note that time elapsed from the vessel cannulation to cardiac tamponade first signs does not preclude this procedure as a cause of this fatal complications.

Thoracic epidural analgesia in anaesthesia for liver transplantation: the 10-year experience of a single centre.

BACKGROUND: Improvements in operating techniques, methods of anaesthesia and postoperative care in liver transplantation (LT) contribute to better outcomes. In order to restrict postoperative mechanical ventilation, a thoracic epidural analgesia (TEA) has been performed in our centre since 2000. In this report we present our 10-year experience of using TEA as a component of LT anaesthesia. MATERIAL/METHODS: TEA was performed, by anaesthetists experienced in this method, on patients qualified for LT, who consented and met inclusion criteria: INR<1.5, APTT<45s and platelets >70 G/L. Since 2008 the decision to insert an epidural catheter has been additionally supported by thromboelastometry. We assessed extubation time, frequency of complications of TEA and undesired accidents. RESULTS: From 279 patients undergoing LT, TEA was performed on 67 (24%), and from these 56 (84%) were extubated in the operating theatre. There were 5 cases of unsatisfactory thoracic epidural analgesia. Only 1 epidural catheter was removed accidentally, on the 2nd postoperative day. None of the complications of TEA were observed in the TEA group. CONCLUSIONS: Based on our observations, it can be assumed that TEA done by experienced an anaesthetist is a safe component of anaesthesia in selected groups of patients undergoing LT, and allows for early extubation.

The use of thromboelastometry in the assessment of hemostasis during orthotopic liver transplantation reduces the demand for blood products.

BACKGROUND: Bleeding due to fibrinolysis is a serious intraoperative complication during orthotopic liver transplantation (OLT). For a number of years aprotinin was used to minimize risk of this complication. This drug was however banned in 2007 and substituted with other antifibrinolytics. The aim of the study was to assess the potential of intraoperative thromboelastometry to evaluate hemostasis and channelize antifibrinolytic therapy. MATERIAL/METHODS: Since ban on aprotinin, 39 patients underwent OLT in our center with no monitoring of fibrinolysis (NMF). Severe disturbances of hemostasis assessed clinically only as a need for blood and blood products transfusion and were treated with transfusion of fresh frozen plasma only. In 2008 we started to use thromboelastometry (ROTEM group, n=39), which allowed for targeted treatment of hyperfibrinolysis with tranexamic acid. RESULTS: The need for blood transfusion in ROTEM group was insignificantly a lower than in NMF group (4.1±4.76 vs 5.53±4.89 units, p=0.2). Patients from ROTEM group required also less plasma transfusions (10.01±7.47 vs 13.15±6.62, p=0.06). Severe fibrinolysis was found in 3 patients from ROTEM group (7.7%) and was treated with tranexamic acid. CONCLUSIONS: Thromboelastometry provides an immediate diagnosis of fibrinolysis, justifies implementation of targeted treatment and confirms effectiveness of the therapy. In a larger study group it can also result in significant minimization of blood products transfusion during OLT.

Electron microscope investigation of the role of Chlamydia sp. in the process of rebuilding the arterial wall. Neoangiogenesis in atherosclerotic plaques in human cervical artery walls.

BACKGROUND: The inflammatory process has an essential impact on the development of atherosclerosis. Three mechanisms are mentioned: 1) possibility of direct development of Chlamydia infection in the vicinity of the blood vessel wall; 2) impact of persistent or recurrrent Chlamydia infection on the increased blood concentration of risk factors for atherosclerosis; 3) an autoimmunological reaction. MATERIAL/METHODS: Electron microscope examinations were performed on specimens from atherosclerotic lesions of the interior cervical arteries, collected from patients who had undergone endarterectomy. The material came from 8 patients (age from 58 to 72). The specimens were fixed for electron microscopy, and after dehydration were immersed in Spurr resin. Ultrathin slices were examined under a transmission electron microscope. RESULTS: In the successive tested layers nearest the lumen of the vessel we found erythrocytic elements, fibrin, and lipid membranes. In deeper layers there were lymphocytic cells, monocytes, and macrophages loaded with phagocyted lipid material. Under this layer we found in some specimens a coating which had undergone mineralization: calcium structures and cholesterol were overlaid on a proteoglycanate base. Smooth muscles cells had undergone the heaviest proliferation among the cells on artery wall. In the tested material we detected diversified morphological forms of Chlamydia sp. Particular attention should be drawn to the appearance of very young vessel forms, which suggests a process of angiogenesis in the atherosclerotic plaques. CONCLUSIONS: We found that one of the pathogens that may lead to atherosclerotic lesions is Chlamydia sp. The process of atherogenesis in cervical arteries is accompanied by angiogenetic processes.