Pathomechanisms of Non-Traumatic Acute Brain Injury in Critically Ill Patients.

Delirium, an acute alteration in mental status characterized by confusion, inattention and a fluctuating level of arousal, is a common problem in critically ill patients. Delirium prolongs hospital stay and is associated with higher mortality. The pathophysiology of delirium has not been fully elucidated. Neuroinflammation and neurotransmitter imbalance seem to be the most important factors for delirium development. In this review, we present the most important pathomechanisms of delirium in critically ill patients, such as neuroinflammation, neurotransmitter imbalance, hypoxia and hyperoxia, tryptophan pathway disorders, and gut microbiota imbalance. A thorough understanding of delirium pathomechanisms is essential for effective prevention and treatment of this underestimated pathology in critically ill patients.

Length of Stay in Emergency Department by ICD-10 Specific and Non-Specific Diagnoses: A Single-Centre Retrospective Study.

The definition of non-specific presentation at a hospital emergency department (ED) has not yet been formally established. The purpose of this study was to assess the relationships between primary ED diagnoses identified by ICD-10 codes and ED length of stay (LOS). Over the course of three years, we examined 134,675 visits at a tertiary hospital. LOS was examined in groups with specific (internal, surgical, neurological, and traumatic diseases) and non-specific diagnoses. Our secondary objective was to measure LOS by age, day of the week, time of day, and season. The median LOS was 182 min (interquartile range: 99-264 min). LOS was 99 min in the traumatic group, while it was 132 min in the surgical group, 141 min in the non-specific group, 228 min in the internal medicine group, and 237 min in the neurological group. Other determinants of LOS were age, revisits, day of the week, and time of arrival-but not a season of the year. In the non-specific group (21% of all diagnoses), the percentage of hospitalizations was higher than in the specific groups. Our results suggest that in clinical practice, the non-specific group should be redefined to also encompass diagnoses from ICD-10 Chapter XXI (block Z00-Z99).

[Neuroprotective properties of sex hormones]. / Wlasciwosci neuroprotekcyjne hormonów plciowych.

Sex hormones exert a substantial effect on brain function; their action is determined by the predominance of one hormone group over the remaining ones. Estrogens have indirect and direct neuroprotective effects. The indirect effects involve improved function of the vascular endothelium and increased blood flow through the brain. The direct effects (nervous cells and glia) consist in strong antioxidative properties, maintenance of Ca+2 homeostasis, blockage of activating amino acids, modification of tissue and humoral immune responses and inhibition of activity of immediate early genes. Gestagens, on the other hand, prevent neuronal death, inhibit lipid membrane peroxidation, and promote growth of nervous cells and formation of new synapses. The role of sex hormones within the brain is equally important. However, in cases of brain pathology, protective effects of gestagens seem to be much strongly expressed.

[The role of sex steroids in prevention of post-ischaemic brain injury]. / Rola hormonów plciowych w zapobieganiu i leczeniu nastepstw ciezkiego uszkodzenia mózgu.

Sex steroids play an important role in neuroprotection following brain injury. Although their protective action has been found to be effective in many experimental animal models, their use in humans remains controversial. Many authors have shown that the frequency and extent of post-ischaemic damage is sex-dependent, and even low concentrations of estrogens are neuroprotective, but not therapeutic. The authors have summarized the current knowledge of neuroprotection by sex steroids in experimental and clinical settings. They conclude that direct extrapolation from animals to humans is not possible, and so far, widespread clinical use of sex steroids in humans is not justified.

Hand injuries in polytrauma patients.

Hand and forearm injuries are relatively rare in polytrauma patients; their incidence is estimated at 2-5%. Hand and forearm injuries are usually not life threatening, and, therefore are considered of secondary importance, replaced by serious injuries of other body parts. However, they should be treated immediately after stabilization of the general condition of patients, as their delayed management may result in serious dysfunction of the hand. The aim of this study was to determine the incidence, distribution and methods of treatment of hand and forearm injuries in patients treated at the Polytrauma Centre of the SPSK 1 in Szczecin over the period of 4 years. Medical records of 16 patients, 11 men (65%) and 5 women (35%) with a mean age of 34 years (range 19-62) who were treated at the Polytrauma Centre and sustained an additional injury to the hand and/or forearm were analyzed. Medical records of 16 patients, 11 men (65%) and 5 women (35%) at the mean age of 34 years (range 19-62) who were treated in Polytrauma Centre and sustained an additional injury to the hand and/or forearm were analysed. The most common component of polytrauma with associated hand injury was major bone fractures (spine, pelvis and extremities) - 12 cases (70%), followed by chest - 11 (65%), maxillofacial - 9 (53%), brain - 8 (47%) and abdominal injuries - 5 (29%). The most common injury of the distal upper limb was fracture of the distal radius - 9 patients (53%). Two patients sustained excessive crush-degloving injuries which were the primary cause of their admission to the Polytrauma Centre. Nine patients required surgery, predominantly fixation of the distal radius with a plate. All patients survived. The importance of the correct management of hand injuries performed promptly after stabilization of the general condition of polytraumatized patients was emphasized.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice.

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.

Incidence and etiology of mortality in polytrauma patients: an analysis of material from Multitrauma Centre of the University Teaching Hospital no 1 in Szczecin, over a period of 3 years (2017-2019).

<b>Introduction:</b> The pattern of traumatic death is a subject of great interest in the worldwide literature. Most studies have aimed to improve trauma care and raise awareness of avoidable fatal complications. <br><b>Aim:</b> The objective of the present study was an epidemiological and clinical analysis of causes of traumatic death of patients treated at the Multitrauma Centre of the University Teaching Hospital No 1 in Szczecin, over a period of 3 years (2017-2019). <br><b>Material and methods:</b> The study material comprised medical data of 32 patients with a mean age of 63 years, who died due to polytrauma injury. The time of death form admission to the Multitrauma Centre, primary cause of death, spectrum and sites of injuries, as well as method of treatment (operative or conservative) were variables considered in the analysis. <br><b>Results:</b> The predominant mechanisms of injury were traffic accidents - 22 cases (69%) followed by falls from a height 8 (25%) and other mechanism - 2 cases (6%). The most common primary cause of death was brain injury - 17 patients (53%) followed by pelvic or spinal fractures - 5 (16%). The predominant constituents of polytrauma were bony injuries (pelvis, spine and limbs) - 28 cases (87%), followed by head injuries - 25 (78%), chest - 24 (75%) and abdominal injuries - 17 (53%). Eighteen patients (56%) required operative treatment; craniotomy for brain injuries was the most commonly performed - in 11 patients, followed by laparotomy - in 5. Five other patients underwent an endovascular procedure - pelvic artery embolization. Twelve patients (38%) died in the first two days from admission to the trauma center, 5 (16%) in the first week and 15 over one week form admission. <br><b>Conclusions:</b> Head injuries, pelvic fractures with associated retroperitoneal bleeding and severe injuries affecting several body parts were identified as the most dangerous for the survival of polytrauma patients. A trend to decrease mortality due to hemorrhagic shock was observed, but it remains unchanged for central nervous system injuries.

An analysis of causes of trauma, spectrum of injuries and treatment outcomes in patients treated at Multitrauma Centre of the University Teaching Hospital No 1 in Szczecin in 2015. Comparison of results from years 2015 and 2007.

INTRODUCTION: Multitrauma is defined as injury involving two or more different body parts, with a condition that at least one of these injuries is life-threatening. They represent serious traumas, requiring treatment in the intensive care units and frequently surgical intervention. AIM: The objective of this study was epidemiological and clinical analysis of patients treated in 2015 year in Multitrauma Centre of the University Teaching Hospital no 1 in Szczecin, and comparison the results with outcomes of similar study conducted in the same Centre in 2007 year. MATERIAL: Clinical material comprised medical notes of 82 patients, 52 men (63%) and 30 women (37%), with a mean age of 44 years, who sustained multitrauma injuries. An analysis included causes of traumas, spectrum of injuries, involvement of body parts, methods and outcomes of the treatment. RESULTS: The most common cause of multitrauma was traffic accident - 45 cases (55%), followed by fall from height - 22 (27%) and other mechanism - 15 (18%). The most frequent component of multitrauma made bone fractures (spine, pelvis, limbs) - 64 cases (78%), followed by head traumas - 63 (77%), chest - 53 (65%) and abdominal 30 (36%) injuries. A total of 48 patients (58%) required surgical intervention, the most frequently fixation of bone fractures - 24 patients (29%), repair of abdominal and head injuries - 18 (22%) either. Of 82 treated patients 64 (78%) survived and 18 (22%) died. A mean period of stay in Multitrauma Centre was 23 days for survived patients and 17 days for those who died. Comparing to similar analysis conducted 8 years earlier, a change in involvement of particular body parts comprising multitrauma injury was observed: number of head injuries increased of 14%, number of chest traumas and bone fractures decreased of 21% and 11%, respectively. The survival rate improved of 10%.

Fatal outcome of spontaneous cerebral and intraventricular hemorrhage in a child with idiopathic thrombocytopenic purpura (ITP)--case report.

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is the most prevalent acquired hemorrhagic diathesis in children characterised by antibody-mediated destruction of platelets. ITP is generally a self-limiting benign disorder but despite this good prognosis, ITP carries the risk of severe bleeding (mainly intracranial) that may threaten the child's life. CASE REPORT: We describe a case of a 5-year-old girl with idiopathic thrombocytopenic purpura in the course of EBV infection with massive cerebral and intraventricular hemorrhage and fatal outcome. CONCLUSION: This extremely rare case of intracranial haemorrhage in a child with ITP coexisting with EBV infection (a likely additional risk factor for hemorrhage) deserves attention considering the fatal outcome despite intensive treatment.

The influence of controlled hypotension on splanchnic mucosal perfusion using gastric tonometry in patients undergoing resection of meningioma.

BACKGROUND: The aim of our research was to evaluate the influence of general anesthesia with controlled nitroglycerin-induced hypotension on splanchnic mucosal perfusion using gastric tonometry. MATERIAL/METHODS: In six patients (1 female, 5 males, median age 46 years, range 32-62) undergoing elective resection of meningiomas, measurements of gastric mucosal perfusion were taken by nasogastric tonometry. Controlled hypotension was initiated after craniotomy and terminated prior to hemostasis procedures. The mean arterial blood pressure (MAP) was maintained 25-30% below initial parameters during controlled hypotension. The adequacy of perfusion was defined by the intramucosal pH (pHi) and the difference between arterial and intramucosal pH (pHGAP). All parameters were analyzed before the induction of controlled hypotension, after the 1st, 2nd, and 3rd hour, and 1 hour after the termination of controlled hypotension. RESULTS: The MAP decreased during controlled hypotension by ca. 26.5% (min. 21.1%; max 31.6%). The lower MAP was accompanied by a statistically significant increase in heart rate. A significant increase from baseline in regional prCO2 was seen after the 1st, 2nd, and 3rd hour of controlled hypotension. Intramucosal pH values decreased significantly during the same period, from 7.428+/-0.032 to 7.372+/-0.015. Despite these statistically significant differences during controlled hypotension, the pHi values were always greater than 7.35, and the pHGAP values were lower than 0.05, which were recognized as being within the normal range. CONCLUSIONS: Controlled hypotension allows accurate evaluation of the blood flow quality at the level of microcirculation. Mild controlled hypotension slightly alters splanchnic mucosal perfusion, but does not lead to ischemia and hypoxia in tissues.

The rate of loss of eyelid reflex following thiopental administration in hypo- and hypergonadism in rabbits.

BACKGROUND: The aim of this research was to explain whether different hormonal conditions caused by disturbed concentrations of estrogens and progesterone might lead to alteration of CNS reaction following administration of the hypnotic agent thiopental. The investigated factor was the rate of loss of the eyelid reflex after intravenous thiopental administration, since this corresponds with loss of consciousness. MATERIAL/METHODS: The investigation was performed in 24 sexually mature female Chinchilla rabbits divided into 4 groups of 6 rabbits each. The animals were oophorectomized (hypoprogesterone/hypoestrogen), hyperestrogen (sham surgery plus estradiol injections), hyperprogesterone (sham surgery plus 17 alpha-hydroxyprogesterone injections), or normal (sham surgery). Twelve weeks later, thiopental (40 mg/ml) was infused through the intravenous cannula at a constant rate (90 ml/hour) until loss of the eyelid reflex, at which time blood was sampled for determination of thiopental, b-estradiol, progesterone and 17 alpha-hydroxyprogesterone concentrations. The ANOVA and Tukey tests were applied in statistical analysis (p=0.05). RESULTS: Hyperprogesterone rabbits lost consciousness faster (138 +/- 34.6 sec), at a lower plasma thiopental concentration (46.3 +/- 6.6 microg/ml), and required less thiopental (24.63 +/- 6.44 mg/kg) than controls; hypoprogesterone rabbits lost consciousness slower (207.5 +/- 30.9 sec), at a higher plasma thiopental concentration (129.2 +/- 24.9 microg/ml), and required more thiopental (38.51 +/- 2.33 mg/kg) than controls. The time of sleep induction in the control group was 190 +/- 25.7 sec.; the serum thiopental concentration was 77.8 +/- 13.9 microg/ml, and the total thiopental consumption was 35.8 +/- 3.51 mg/kg. Estrogen status has no effect. CONCLUSIONS: Various hormonal states are accompanied by different CNS reactions to thiopental. Among the studied groups of sex steroids, only progestins significantly modify the CNS response to barbiturate infusion.