Harmonic scalpel versus traditional ligation in axillary dissection for breast cancer: a retrospective multivariate analysis.

INTRODUCTION: The aim of this pilot retrospective study is to evaluate the complication rate in patients after axillary dissection comparing preparation with harmonic scalpel vs traditional ligation technique, and to analyse risk factors for complications occurrence. METHODS: 144 patients with 148 axillary dissections operated in a single centre between January 2014 and 2019 were included into the study. Axillary dissection was performed using harmonic scalpel in 73 and absorbable ligations in 70 cases. RESULTS: Seroma formation was observed in 41 patients (56.2%) in the harmonic scalpel group and in 21 patients (30.0%) in the ligations group (p=0.003). The mean period from the surgery to drain removal was 4.0 days in the harmonic scalpel group and 3.0 days in the ligations group (p<0.001). The mean amount of the drained fluid after mastectomy was 300.9 ml in the harmonic scalpel group and 168.7 ml in the ligations group (p=0.005); after breast conserving surgery, it was 241.9 ml and 107.4 ml, respectively (p =0.023). CONCLUSION: In comparison with traditional ligations with absorbable material, axillary dissection using harmonic scalpel significantly increases the risk of postoperative seroma formation, prolongs the time from the surgery to drain removal, and increases the amount of drained fluid.

Randomized evaluation of fibrinogen vs placebo in complex cardiovascular surgery (REPLACE): a double-blind phase III study of haemostatic therapy.

BACKGROUND: Single-dose human fibrinogen concentrate (FCH) might have haemostatic benefits in complex cardiovascular surgery. METHODS: Patients undergoing elective aortic surgery requiring cardiopulmonary bypass were randomly assigned to receive FCH or placebo. Study medication was administered to patients with a 5 min bleeding mass of 60-250 g after separation from bypass and surgical haemostasis. A standardized algorithm for allogeneic blood product transfusion was followed if bleeding continued after study medication. RESULTS: 519 patients from 34 centres were randomized, of whom 152 (29%) met inclusion criteria for study medication. Median (IQR) pretreatment 5 min bleeding mass was 107 (76-138) and 91 (71-112) g in the FCH and placebo groups, respectively (P=0.13). More allogeneic blood product units were administered during the first 24 h after FCH, 5.0 (2.0-11.0), when compared with placebo, 3.0 (0.0-7.0), P=0.026. Fewer patients avoided transfusion in the FCH group (15.4%) compared with placebo (28.4%), P=0.047. The FCH immediately increased plasma fibrinogen concentration and fibrin-based clot strength. Adverse event rates were comparable in each group. CONCLUSIONS: Human fibrinogen concentrate was associated with increased allogeneic blood product transfusion, an unexpected finding contrary to previous studies. Human fibrinogen concentrate may not be effective in this setting when administered according to 5-minute bleeding mass. Low bleeding rates and normal-range plasma fibrinogen concentrations before study medication, and variability in adherence to the complex transfusion algorithm, may have contributed to these results. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier no. NCT01475669; EudraCT trial no. 2011-002685-20.

Transfusion-related acute lung injury: report of two cases.

Transfusion-related acute lung injury (TRALI) is a severe life-threatening complication of blood transfusion, characterized by acute lung injury developing within 2-6 h of transfusion. However, TRALI is difficult to diagnose, and the initial report or suspicion of TRALI depends on close collaboration between clinical departments and transfusion centres. A total of 17 adverse post-transfusion reactions were reported to the Blood Centre of the University Hospital Ostrava as suspected TRALI between 2005 and 2010. We report two cases of serious TRALI with different pathogenetic mechanisms.

[Cardiac surgery as a significant interference with a patient coagulation status]. / Operace srdce jako závazný zásah do koagulacního stavu pacienta.

Cardiac surgery has been advancing intensively in recent years. However, it is often forgotten that cardiac surgery interventions represent a significant interference with patient's coagulation status. This paper summarizes the main processes in the course cardiac surgery that lead to coagulation disorder. These include: * haemodilution resulting from extracorporeal circuits crystalloid priming and the use of cardioplegic solutions leading to the reduction in coagulation factors concentration and the thrombocytes count * full heparinisation during extracorporeal circulation that represents a significant interference with coagulation that may persist for some time even after all heparin has been bound * contact of the blood with inorganic surface that results in an activation of the coagulation cascade and subsequent consumption of coagulation factors and thrombocytes * surgery-related trauma with activation of the external coagulation pathway leading to activation of the coagulation cascade and subsequent consumption of coagulation factors and thrombocytes * blood re-transfusion from the pericardial cavity and subsequent activation of the external coagulation pathway leading to consumption of coagulation factors and thrombocytes * hypothermia leading to thrombocyte dysfunction and initiation of fibrinolysis * blood loss furthering the haemodilution and reduction in coagulation factors concentration and thrombocytes count. The overview provided suggests that cardiac surgery conducted with the support of extracorporeal circuit represents a significant interference with the coagulation status of the patient. Awareness of the above listed changes is necessary to secure correct post-operative management of coagulation disorders.

[Pre-operative care for cardiac surgery patients with cold antibody disorder, cryoglobulinaemia and cryofibrinogenemia]. / Péce a pacienty s nemocí chladovych protilátek, kryoglobulinemií a kryofibrinogenemií pred kardiochirurgickými zákroky.

We present an example of a patient with confirmed cold agglutinin disease who underwent cardiac surgery in hypothermia to illustrate a known fact that, when exposed to cold, cold agglutinins induce haemolysis of erythrocytes and that cryoglobulins and cryofibrinogens may, upon exposition to cold during a surgery under hypothermia, precipitate or gelify and thus increase plasma viscosity and damage microcirculation. Detailed immunological and haematological investigations in all patients awaiting cardiac surgery with a risk of developing hypothermia is not advantageous considering the low number of patients with clinical and laboratory signs of cold agglutinin disease, autoimmune haemolytic anaemia or paroxysmal cold haemoglobinuria and considering that these investigations, in addition, might not detect cryoglobulinaemia and cryofibrinogenemia. Identification of in-risk patients from the warning signs in the medical history, physical or basal laboratory testing who would subsequently undergo confirmatory investigations to verify the presence of these entities and define them accurately might be a potential solution to this clinical issue. Cardiac surgery strategy and peri-operative care should be tailored to the results of these investigations. Well-structured, practiced and functional cooperation between clinicians and laboratory personnel is a prerequisite for success in these circumstances.

[Preoperative preparation and examinations before scheduled cardiosurgical intervention]. / Predoperacní príprava a vysetrení pacienta pred plánovaným kardiochirurgickým výkonem.

In our article we inform about complete preoperative preparation and about required examinations before the scheduled cardiosurgical procedure. Important part of the preoperative preparation is also detailed instruction about the character of the operation, a way of its realization and about the operation risks. In the end of this article we discus the instruction of the patient about the types of the valvular prosthesis.

[Pericardiocentesis afrer heart surgery--our experience]. / Perikardiocentéza po srdecní [corrected] operaci--nase zkusenosti.

UNLABELLED: Pericardial effusion after cardiac surgery is common, but only in a small part of patients it has progressive character and cardiac tamponade occurs. Accurate diagnosis and well-timed pericardiocentesis are necessary to effective management of this life threatening complication. The study aimed at presentation of our centre outcomes of echocardiographically-guided pericardiocentesis in patients after cardiac surgery. METHODS: Between December 2005 and November 2007, 2,232 patients underwent open-heart surgery in our centre. At 48 (2.2%) of them pericardiocentesis for clinically significant pericardial effusion was performed. RESULTS: Pericardiocentesis was significantly more frequent after valve surgery (7.1%, p < 0.001), aortic root surgery (8.2%, p < 0.001) and surgical ablation of atrial fibrillation (6.6%, p < 0.001), i.e. in patients who had received postoperative anticoagulation therapy. Echo-guided pericardiocentesis was technically and therapeutically successful in 100% of cases and no complications were registered. The time elapsed between surgery and puncture was in range 6 to 80 days (median, 13 days). The median volume initially aspirated was 450 ml (range, 50 to 1,550 ml). Forty five patients (93.8%) had extended catheter drainage with active suction, the median duration of the drainage was 1 day (range, 1 to 6 days), the mean volume of catheter drainage was 328 ml (median, 145 ml; range, 20 to 2,950 ml). Four patients (8.3%) required repeated pericardiocenteses because of recurrence of significant pericadial effusion. Extended pericardial catheter drainage (after initial evacuation of the effusion) was associated with a significant reduction of recurrence of significant pericadial effusion and with lower probability of repeated pericardiocentesis. We can conclude, echo-guided pericardiocentesis was effective and safe method for primary treatment of postoperative pericardial effusions.

[Effect of surgical treatment of atrial fibrillation on the attainment and maintenance of sinus rhythm in patients undergoing concomitant cardiac surgery--short-term results]. / Efekt chirurgické lécby fibrilace síní na dosazení a udrzení sinusového rytmu u nemocných podstupujících sdruzený kardiochirurgický výkon--krátkodobé výsledky.

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. It is associated with higher morbidity and mortality of patients. Cryoablation was introduced to the current practise in cardiac surgery as a non-pharmacological method of therapy of atrial fibrillation. The aim of the study was to assess the effect of surgical ablation of atrial fibrillation on the attainment and maintenance of sinus rhythm in patients undergoing concomitant cardiac surgery. METHODS AND RESULTS: Ninety four consecutive patients with atrial fibrillation (paroxysmal, persistent or permanent) were followed up prospectivelly. The mean age was 67.8 years; there were 39 (41.5%) women in the study group. Forty two patients (44.7%) had paroxysmal or persistent atrial fibrillation and 52 (55.3%) of them had permanent atrial fibrillation before surgery. Patients with permanent atrial fibrillation had significantly bigger preoperative left atrial diameter (51.2 versus 46.6 mm) and more severe tricuspid regurgitation (grade 2.3/4 versus grade 1.4/4) compared to the group with paroxysmal and persistent atrial fibrillation. Mitral valve surgery was significantly more frequent in patients with permanent atrial fibrillation too. Operations were performed between January 2005 and July 2006 using flexible argon-based cryoablative device. Sinus rhythm was achieved statistically significantly more frequently in patients with preoperative paroxysmal and persistent atrial fibrillation in comparison with patients with permanent atrial fibrillation--at discharge, 1, 3.5 and 6 months after operation (90.5-96.3 % versus 50-65.9%). At 12 months it was only statistical trend (84.6% versus 63.3%). Kaplan-Meier analysis demonstrated a 79.4% freedom from atrial fibrillation at 12 months. Preoperative atrial size and duration of atrial fibrillation were the most significant negative predictors of maintenance of sinus rhythm. Four patients (9.3%) required postoperative permanent pacemaker placement. Ischemic stroke occured in 5 (5.3%) patients. Thirty-day motality was 12.9% (12 patients). CONCLUSIONS: Perioperative ablation of atrial fibrillation using cryoenergy is effective therapeutic method for restoring and maintenance of sinus rhythm in relatively high proportion of patients. The most significant predictors of late recurrence are preoperative atrial size and duration of atrial fibrillation. This non-pharmacological method should be routinely used in patients undergoing concomitant cardiac surgery.

[Atrial transport function after surgical ablation of atrial fibrillation using cryoenergy]. / Transportní funkce síní po chirurgické ablaci fibrilace síní pomocí kryoenergie.

BACKGROUND: Surgical ablation is one of the most effective techniques for treatment of atrial fibrillation. Stable sinus rhythm is achieved and effective atrial contractions are restored in the majority of patients. The aim of the prospective study is to assess the presence of atrial transport function after surgical ablation of atrial fibrillation using cryoenergy and to evaluate predictors of the procedural success. METHODS AND RESULTS: Between January 2005 and September 2006, 100 consecutive patients underwent left atrium cryoablation as a concomitant cardiac procedure. Their mean age was 67.6 years (range 50 to 82 years), there were 41 (41 %) women. Forty six patients (46 %) suffered from paroxysmal or persistent atrial fibrillation and 54 (54 %) of them from permanent atrial fibrillation before surgery. Atrial mechanical function was assessed by echocardiography (pulsed Doppler examination of the mitral and tricuspidal inflow, presence of the atrial filling [A] wave) after 3.5, 6, 12 and 18 months postoperatively. 79.6 % of patients, who have had sinus rhythm at 3.5 months, were free from atrial fibrillation at 18 months after surgery. The effective left atrial contractions were present at 3.5, 6, 12 and 18 months postoperatively in 70.2 %, 71.9 %, 81.4 % and 73.5 % of patients and we found right atrial transport function in 97 %, 95.3 %, 97.7 % and 97.1 % of patients. There was no significant difference between group with paroxysmal or persistent atrial fibrillation and permanent fibrillation. Negative predictors for restoration of the left atrial transport function were: preoperative mitral stenosis (at 3.5 and 6 months, p=0.02 and p=0.03 respectively), bigger left atrial dimension prior to procedure (only at 3.5 months, p=0.01) and severity of tricuspid regurgitation before surgery (only at 18 months, p=0.01). An ischaemic stroke occured in 7 %. Thirty-day motality was 12 % (12 patients). CONCLUSIONS: Left atrial mechanical funtion was detected in 70-80 % of patients and right atrial function in 95-98 % of patients with sinus rhythm during follow-up of 18 months. Preoperative left atrial dimension, presence of mitral stenosis and severity of tricuspid regurgitation were the most significant predictors for postoperative restoration of the left atrial transport function. Significant reduction in occurence of ischaemic stroke by surgical ablation was not achieved.

Combined surgical and endovascular treatment of extensive thoracic aortic aneurysm.

AIM: Patients with extensive aneurysm involving ascending aorta, aortic arch and descending aorta are usually treated by sequential operations. For these patients we can also use combined surgical and endovascular treatment. The experience with this procedure published in the literature is very limited. We report our experience in the ''elephant trunk'' technique followed by an endovascular stent-grafting of the descending thoracic aorta in a small group of three consecutive patients with extensive thoracic aortic aneurysm. METHODS: Three consecutive patients with extensive thoracic aortic aneurysm or chronic dissection underwent combined surgical and endovascular treatment between January and December 2004. The procedure was carried out as a two-stage procedure. During the first stage aortic arch was replaced using the elephant-trunk'' method and during the second stage the stentgrafting of the descending aorta was performed. RESULTS: All three patients were treated successfully. There was no death, no endoleak and no permanent neurological deficit. One patient had a transient paraparesis. In all patients the spiral CT demonstrated excellent technical result without endoleak and with thrombosis of the paraprosthetic space. CONCLUSIONS: We can conclude, that the combined surgical and endovascular treatment of extensive thoracic aortic aneurysm is a feasible method which could reduce mortality and morbidity. In our institution the elephant trunk technique followed by an endovascular stent-grafting of the descending aorta is the preferred method of treatment in patients with extensive thoracic aortic aneurysm involving ascending aorta, aortic arch and descending aorta.

[Surgical treatment of infective endocarditis: 8 year experience]. / Chirurgická lécba aktivní infekcní endokarditidy: 8leté zkusenosti.

BACKGROUND: A retrospective study analysing effects of surgical treatment of active infective endocarditis was performed in our centre between January 1998 and December 2005. METHODS AND RESULTS: 57 consecutive patients with infective endocarditis underwent surgical intervention in active phase of infection (fulfilment of Durack diagnostic criteria, persisting elevation CRP at the time of cardiac surgery, indications for surgery according to actual guidelines of the Czech Society of Cardiology). Male to female ratio was 38:19. The patients' mean age was 52.5 years without any significant differences among men and women. The most frequent causative agents were staphylococci--28.1 % and streptococci--19.3 %. 26 cases of aortic valve involvement were the most frequent, followed by 21 cases of mitral endocarditis, and 7 cases were both aortic and mitral valve endocarditis. 3 cases of tricuspid endocarditis were also observed. Native valve endocarditis prevailed over the prosthetic ones--49 versus 8. Surgery was most often performed using a mechanical prosthesis (45 cases), bioprostheses were implanted in 13 patients and 6 patients underwent mitral or tricuspid valve repair operation. In 1 patient, the procedure was complemented with mitral valve annuloplasty, and in 5 patients, the operation was completed with tricuspid annuloplasty--because of significant regurgitation of other aetiology. Coronary artery bypass surgery (at the same time) was necessary in 9 patients. Surgery was followed by a significant shift from classes III and IV to classes I and II of NYHA classification. Relapsing or recurrent endocarditis developed in 7 %. Thirty-day mortality of patients who had undergone surgery for active infective endocarditis was 15.8 %, 9 patients died. During follow up period 7 patients died, the overall mortality was 28.1 %. Survivors were followed up for 0.5-90 (median 40) months. CONCLUSIONS: Operation for active infective endocarditis carries a relatively higher mortality in comparison with elective surgery. Nevertheless, this is acceptable because the operation in active phase is enforced by life-threatening complications and it also reduces assumed mortality at conservative therapy. Our results are comparable with data from other studies.

[Traumatic tricuspid regurgitation: case report]. / Traumatická trikuspidální regurgitace: kazuistika.

Traumatic tricuspid regurgitation is a rare disease owing to penetrating or nonpenetrating thoracic trauma. In the last 40 years, since motorism is increasing, this disease can be seen more frequently. In most cases, rupture of chordae tendinae on the tricuspid valve, damage of the front papillary muscle and rupture of the tricuspid valve leaflets. On an acute stage, the damage of the valve can remain undiagnosed. Later on, the patient might have no symptoms; however, symtoms of right heart failure indicating an operation appear. This case-study is concerned with a patient with traumatic tricuspid regurgitation.

[Case reports of family members with multiple occurrences of aortic dissection]. / Kazuistika clenu rodiny s mnohocetným výskytem aortální disekce.

Aortal dissection belongs to the group of aortal diseases with a high mortality rate and varied clinical account. This disease does not appear very often and therefore it is often diagnosed late. Diagnostic and therapeutic developments have recently improved. Classification and indication criteria about prophylactic interventions on aorta have become more specific. It leads to the gradual decrease of mortality caused by this disease. Frequent accumulation of familiar aortal dissection was described. It can be important for the early identification of individuals at risk. In our casuistry we describe a family with the accumulation of aortal dissection coinciding with Marfan syndrome from the mother's side and the prevalence of this disease in siblings from their patient's father. The evident predisposition was not clearly demonstrated in these cases. We also examined and began to dispenser other members of the family but we did not find an evident predisposition factor. We would like to emphasize the importance of good interdisciplinary and institutional cooperation in diagnostic and treatment of this disease. Further we want to emphasize the contribution of careful sampling of familiar anamnesis in the cases stricken with the disease. We focused on sudden death. It is well known that the gene analysis may contribute to the identification of individuals at risk in these families. We do not have this possibility in our country now.

[Is obesity a real risk factor in cardiosurgical procedures?]. / Je obezita skutecne rizikovým faktorem u kardiochirurgických operací?

AIM: Obesity is generally presented to be a risk factor in surgical procedures including the cardiac ones. The aim of this work was to conduct a retrospective study comparing surgical results of the cardiosurgical procedures depending on each patient's body mass index data (BMI). METHODOLOGY: All 4266 patients operated by our team during 1998-2002 have been included in the study. The patient subjects were allocated in 5 groups according to their individual BMIs. Preoperative, peroperative and postoperative data of all groups were compared. RESULTS: There were no significant differences in the preoperative and peroperative data between the groups. The postoperative results showed no statistical differences between the individual groups, indicating a trend towards better results in the groups with higher BMIs. On the contrary, the results of the group with the BMI of less than 20 kg/m2 were the worst, however they were also of no statistical significance. CONCLUSION: The restrospective study did not prove the obesity to be a risk factor in cardiosurgical procedures. On the contrary, it suggested the BMI of less than 20 kg/m2 to be a risk factor.

[Options for combining surgical and endovascular techniques in the management of large aneurysms and dissections of the thoracic aorta]. / Moznosti pouzití kombinace chirurgických a endovaskulárních technik v lécbe rozsáhlých aneuryzmat a disekcí hrudní aorty.

The surgical management of aneurysms and dissections of the thoracic aorta, as well as their endovascular management, all have their technical and medical limits. The aim of this work is to point out possibility for combination of the both treatment methods and to share our first practical experience with this procedure. The procedures conducted have been divided into the following groups: combined procedures, where the surgical part enables implantation of the stentgraft into the descending aorta or is managing imperfect results of such implantations, procedures, where combining the surgical and endovascular treatment lowers operational stress of the patient, as the extracorporeal circulation and the circulation arrest are not required, procedures, where advantages of both the surgical treatment in the region of the aortic arch and the endovascular treatment in the region of the descending aorta, are combined. Using the combination of both the surgical and endovascular techniques in the management of the large aneurysms and dissections of the thoracic aorta, appears to be a perspective method. The patient may benefit from its lower perioperative risk rates and lower postoperative morbidity rates. A good long-term effect of the above treatment method may be expected, however, it has to be verified in long-term patient studies.

Myocardial function in early hours after coronary artery bypass grafting in patients with left ventricular dysfunction: comparison of blood and crystalloid cardioplegia.

AIM: This study was done to evaluate a myocardial function in the early hours after coronary artery bypass grafting (CABG) in patients with left ventricular dysfunction and to compare blood and crystalloid cardioplegia. METHODS: One hundred consecutive patients with left ventricular ejection fraction <35% scheduled for CABG were randomly divided into 2 groups. In the 1st group we used cold blood cardioplegia, in the 2nd group cold crystalloid cardioplegia. We measured hemodynamic data in the early hours after operation, enzyme release and we collected relevant clinical data. RESULTS: The mortality rate in the crystalloid and blood cardioplegia group was 2% and 0%, respectively. We didn't find any significant difference in the incidence of perioperative myocardial infarction, arrhythmia and use of intraaortic balloon pumping between groups. Differences between groups were found in the enzymatic response. Average creatine kinase and MB isoenzyme of creatine kinase (CK-MB), was lower in the blood cardioplegia group lower during the whole examined period. We also found some significant differences in hemodynamic data in the postoperative period. In the crystalloid cardioplegia group there was a decrease in left ventricular stroke work index immediately after operation. The preoperative value was reached in about 2 hours after operation. On the other hand, we didn't find this decrease in the blood cardioplegia group. This difference between groups was statistically significant. Other hemodynamic data didn't show any significant difference. CONCLUSION: Blood cardioplegia shows earlier improvement of myocardial function after the operation. It could be beneficial in patients with severe left ventricular dysfunction.

Comparison between blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary surgery.

This study was done to compare the protective effect of blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Sixty consecutive patients with left ventricular ejection fraction < 35% scheduled for CABG with the use of cardiopulmonary bypass without additional procedures were randomly divided into two groups. In the first group we used cold blood cardioplegia, in the second group cold crystalloid cardioplegia, both delivered only ortogradely. We measured hemodynamic data in early hours after operation, enzyme release and we collected other clinical data which could be influenced by perioperative myocardial protection. There was no death in either group. We also didn't find any significant difference in incidence of perioperative myocardial infarction, arrhythmias and use of intraaortic balloon pumping between both groups. In an early hours after operation in the group with blood cardioplegia we found significantly better hemodynamic data (LVSWI, RVSWI) and significantly lower enzyme release. We conclude, that cold blood cardioplegia shows superior perioperative myocardial protection resulting in earlier restoration of myocardial function. This difference could be important in patients with high degree of left ventricular dysfunction.

[Indications for surgical intervention in acute pancreatitis]. / Príspevek k indikacím chirurgické intervence u akutních pankreatitid.

The authors analyze in detail a group of 48 patients treated on account of acute pancreatitis in 1988. As regards the severity and prognosis of the disease, they divide it according to the Mainzer classification into three groups. The first mildest one was not subjected to acute operation. Serious cases in group 2 and 3 called in a total of 22 cases for operation. The authors discuss in detail indications for surgical intervention from four basic aspects: laboratory findings, ultrasonographic and CT examination, the clinical picture and character of the exudate in the abdominal cavity. It is essential to evaluate in a comprehensive way all symptoms and the dynamics of their development, in particular, however, the clinical picture of the disease. The possible lack of of some paraclinical examinations (ultrasonography, CT) must not play a decisive role for the indication.

[Resuscitation of a patient with deep hypothermia using extracorporeal circulation]. / Resuscitace hluboce podchlazeného nemocného s pouzitím mimotelního obehu.

The case-history describes successful resuscitation of a young man who was found after 15 hours following attempted suicide (intoxication with carbamazepine) in deep hypothermia (19 degrees C) with cardiac arrest. For rewarming the patient extracorporeal circulation was used. The patient was successfully disconnected from the extracorporeal circulation, relieved of the shock incl. severe rhabdomyolysis and intoxication with carbamazepine and discharged to domiciliary treatment without suffering from a neurological deficiency.

Surfactant from neonatal to pediatric ICU: bench and bedside evidence.

Surfactant is a cornerstone of neonatal critical care for the treatment of respiratory distress syndrome of preterm babies. However, other indications have been studied for various clinical conditions both in term neonates and in children beyond neonatal age. A high degree of evidence is not yet available in some cases and this is due to the complex and not yet totally understood physiopathology of the different types of pediatric and neonatal lung injury. We here summarise the state of the art of the bench and bedside knowledge about surfactant use for the respiratory conditions usually cared for in neonatal and pediatric intensive care units. Future research direction will also be presented. On the whole, surfactant is able to improve oxygenation in infection related respiratory failure, pulmonary hemorrhage and meconium aspiration syndrome. Bronchoalveolar lavage with surfactant solution is currently the only means to reduce mortality or need for extracorporeal life support in neonates with meconium aspiration. While surfactant bolus or lavage only improves the oxygenation and ventilatory requirements in other types of postneonatal acute respiratory distress syndrome (ARDS), there seems to be a reduction in the mortality of small infants with RSV-related ARDS.