Pharmacokinetics of dexmedetomidine during analgosedation in ICU patients.

Dexmedetomidine (DEX) is a fairly new alfa2-agonist which has been increasingly used in recent years for analgosedation, mostly because it offers a unique ability of providing both moderate level of sedation and analgesia without respiratory depression. Despite of many papers published, there are still only a few concerning the PK of the drug given as long-term infusion in ICU patients. The aim of this work was to characterize the population pharmacokinetics of dexmedetomidine and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in intensive care unit. This study was performed in the group of 17 males and 10 females patients with a median age of 59.5 years and median body weight of 75 kg. Blood samples for dexmedetomidine assay were collected from arterial catheter, during and after discontinuation of a standard infusion, that ranged from 24 to 102 h. The following covariates were examined to influence dexmedetomidine PK: age, sex, body weight, patients' health status described by Sequential Organ Failure Assessment Score (SOFA), inotropes usage, and infusion duration. The dexmedetomidine PK was best described by a two-compartment model. The typical values of PK parameters were estimated as 27 L for the volume of the central compartment, 87.6 L for the volume of the peripheral compartment, 38.5 L/h (9.2 mL/min/kg for a 70 kg patient) for systemic clearance and 46.4 L/h for the distribution clearance. Those values are consistent with literature findings. We were unable to show any significant relationship between collected covariates and dexmedetomidine PK. This study does not provide sufficient evidence to support the individualization of dexmedetomidine dosing based on age, sex, body weight, SOFA, and infusion duration.

Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients.

INTRODUCTION: Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. MATERIALS AND METHODS: This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. CONCLUSIONS AND DISCUSSION: Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug-drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug-drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug-drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.

The pharmacokinetics of propofol in ICU patients undergoing long-term sedation.

The aim of this study was to characterize the pharmacokinetics (PK) of propofol in ICU patients undergoing long-term sedation and to assess the influence of routinely collected covariates on the PK parameters. Propofol concentration-time profiles were collected from 29 patients. Non-linear mixed-effects modelling in NONMEM 7.2 was used to analyse the observed data. The propofol pharmacokinetics was best described with a three-compartment disposition model. Non-parametric bootstrap and a visual predictive check were used to evaluate the adequacy of the developed model to describe the observations. The typical value of the propofol clearance (1.46 l/min) approximated the hepatic blood flow. The volume of distribution at steady state was high and was equal to 955.1 l, which is consistent with other studies involving propofol in ICU patients. There was no statistically significant covariate relationship between PK parameters and opioid type, SOFA score on the day of admission, APACHE II, predicted death rate, reason for ICU admission (sepsis, trauma or surgery), gender, body weight, age, infusion duration and C-reactive protein concentration. The population PK model was developed successfully to describe the time-course of propofol concentration in ICU patients undergoing prolonged sedation. Despite a very heterogeneous group of patients, consistent PK profiles were observed. Copyright © 2016 John Wiley & Sons, Ltd.

Outcome of acute East African trypanosomiasis in a Polish traveller treated with pentamidine.

BACKGROUND: African trypanosomiasis is a parasitic infection sporadically imported to Europe by tourists or immigrants returning from endemic areas. We present the first and an unusual case of East African trypanosomiasis imported to Poland by a patient returning from a tourist trip to Uganda and Rwanda, which was successfully treated with pentamidine. CASE PRESENTATION: A 61-year-old Polish man was admitted to the Department because of high-grade fever and multi-organ dysfunction after a tourist trip to East Africa. He experienced a single tsetse fly bite during a safari trip to the Queen Elizabeth National Park in Uganda. On admission, his clinical status was severe, with high fever of 41ºC, preceded by chills, bleeding from the gums and oral mucosa, haemorrhages at the sites of venipuncture, numerous ecchymoses, fine-spotted skin rash, tachycardia, hepatosplenomegaly, dehydration, jaundice, dyspnoea, hypoxaemia, generalised oedema and oliguria. There was a typical non-painful trypanosomal chancre with central necrosis and peripheral erythema on his left arm. Laboratory investigations showed leucopenia, thrombocytopenia, haemolytic anaemia, hyperbilirubinaemia, hypoglycaemia, elevated creatinine and urea, high activity of aminotransferases, elevated levels of inflammatory markers, hypoproteinaemia, proteinuria, abnormal clotting and bleeding times, low fibrinogen level, metabolic acidosis, and electrolyte disturbances. A peripheral blood smear showed numerous Trypanosoma brucei trypomastigotes with a massive parasitaemia of 100,000/µl. T. brucei rhodesiense subspecies was finally identified on the basis of the characteristic serum resistance-associated gene using a polymerase chain reaction, and a seroconversion of specific immunoglobulin M and G antibodies in the peripheral blood by enzyme-linked immunosorbent assay. Serological tests for T. brucei gambiense subspecies were negative. A severe clinical course of acute rhodesiense trypanosomiasis with renal failure, respiratory distress, disseminated intravascular coagulation syndrome, haemolysis, liver insufficiency and myocarditis was confirmed. Intensive anti-parasitic and symptomatic treatment was immediately instituted, including intravenous pentamidine, plasmaphereses, oxygen therapy, blood transfusion, catecholamine administration, and fluid infusions, as well as haemostatic, hepatoprotective, anti-inflammatory, antipyretic and diuretic drugs. The final outcome was a full recovery with no late sequelae. CONCLUSION: Sleeping sickness should always be considered in the differential diagnosis of fever in people returning from safari trips to the national parks or nature reserves of sub-Saharan Africa.

The Incidence of Perioperative Hypotension in Patients Undergoing Major Abdominal Surgery with the Use of Arterial Waveform Analysis and the Hypotension Prediction Index Hemodynamic Monitoring-A Retrospective Analysis.

Intraoperative hypotension (IH) is common in patients receiving general anesthesia and can lead to serious complications such as kidney failure, myocardial injury and increased mortality. The Hypotension Prediction Index (HPI) algorithm is a machine learning system that analyzes the arterial pressure waveform and alerts the clinician of an impending hypotension event. The purpose of the study was to compare the frequency of perioperative hypotension in patients undergoing major abdominal surgery with different types of hemodynamic monitoring. The study included 61 patients who were monitored with the arterial pressure-based cardiac output (APCO) technology (FloTrac group) and 62 patients with the Hypotension Prediction Index algorithm (HPI group). Our primary outcome was the time-weighted average (TWA) of hypotension below < 65 mmHg. The median TWA of hypotension in the FloTrac group was 0.31 mmHg versus 0.09 mmHg in the HPI group (p = 0.000009). In the FloTrac group, the average time of hypotension was 27.9 min vs. 8.1 min in the HPI group (p = 0.000023). By applying the HPI algorithm in addition to an arterial waveform analysis alone, we were able to significantly decrease the frequency and duration of perioperative hypotension events in patients who underwent major abdominal surgery.

Massive bleeeding from upper gastrointestinal tract as a symptom of rupture of splenic artery aneurysm to stomach.

BACKGROUND: Splenic artery aneurysm is the most common aneurysm of visceral vessels. Their rupture usually leads to massive bleeding, being a direct life threat. Splenic artery aneurysms usually rupture into the free peritoneal cavity, and much less frequently into the lumen of the gastrointestinal tract. CASE REPORT: We describe the case of a 38-year-old male patient, who, as a result of chronic pancreatitis, developed a false aneurysm of the splenic artery, which initially caused necrosis of the large intestine and bleeding into its lumen, and subsequently necrosis of the posterior stomach wall with the aneurysm rupture to the stomach lumen with a dramatic course. CONCLUSIONS: The case described confirms that splenic artery aneurysm can be a cause of bleeding to both upper and lower parts of the gastrointestinal tract, and the aneurysm rupture is usually of a dramatic and life-threatening course.

Discrete movements of foot epithelium during adhesive locomotion of a land snail.

During the adhesive locomotion of land snails a series of short dark transverse bands, called pedal or foot waves, is visible ifa moving snail's ventral surface is observed through a sheet of glass. Moreover, the mucus secreted from the pedal glands and some pedal epithelial cells forms a thin layer which acts as a glue augmenting adherence, while also acting as a lubricant under the moving parts of the snail's foot. The relationships between velocity and the frequency of pedal waves as well as changes in the volume of small air bubbles under foot waves were analyzed by means of digital recordings made through a glass sheet on which the snails were moving. On the ventral surface of a moving snail foot, the adhering parts of the foot constituted about 80% of the total area, while several moving parts only about 20%. The single moving region of the foot (the pedal wave) amounted to about 3% of snail length. The epithelium in the region of the pedal wave was arched above the substrate and was also more wrinkled than the stationary epithelium, which enabled the forward motion of each specific point of epithelium during the passage of a pedal wave above it. The actual area of epithelium engaged by a pedal wave was at least 30% greater than the area of the epithelium as recorded through a glass sheet. In the region of the pedal wave, the tiny subepithelial muscles acting on the epithelium move it up in the front part of the wave, and then down at the end of the wave, operating vertically in relation to the substrate. In the middle part of the wave, the epithelium only moves forward. In summary, during the adhesive locomotion of snails, the horizontal movement of the ventral surface epithelium proceeds as temporally separate phases of upward, forward and downward movement.

Admission Lactate Concentration, Base Excess, and Alactic Base Excess Predict the 28-Day Inward Mortality in Shock Patients.

Base excess (BE) and lactate concentration may predict mortality in critically ill patients. However, the predictive values of alactic BE (aBE; the sum of BE and lactate), or a combination of BE and lactate are unknown. The study aimed to investigate whether BE, lactate, and aBE measured on admission to ICU may predict the 28-day mortality for patients undergoing any form of shock. In 143 consecutive adults, arterial BE, lactate, and aBE were measured upon ICU admission. Receiver Operating Curve (ROC) characteristics and Cox proportional hazard regression models (adjusted to age, gender, forms of shock, and presence of severe renal failure) were then used to investigate any association between these parameters and 28-day mortality. aBE < −3.63 mmol/L was found to be associated with a hazard ratio of 3.19 (HR; 95% confidence interval (CI): 1.62−6.27) for mortality. Risk of death was higher for BE < −9.5 mmol/L (HR: 4.22; 95% CI: 2.21−8.05), particularly at lactate concentrations > 4.5 mmol/L (HR: 4.62; 95% CI: 2.56−8.33). A 15.71% mortality rate was found for the combined condition of BE > cut-off and lactate < cut-off. When BE was below but lactate above their respective cut-offs, the mortality rate increased to 78.91%. The Cox regression model demonstrated that the predictive values of BE and lactate were mutually independent and additive. The 28-day mortality in shock patients admitted to ICU can be predicted by aBE, but BE and lactate deliver greater prognostic value, particularly when combined. The clinical value of our findings deserves further prospective evaluation.

Echocardiographic evaluation of percutaneous valve repair in patients with mitral regurgitation using the CARILLON system.

BACKGROUND: Dilated cardiomyopathy is characterised by significant enlargement of cardiac chambers, which can lead to functional mitral regurgitation. Surgery is a widely accepted treatment of secondary mitral regurgitation. Conventional cardiac surgery has a high procedural risk and therefore new techniques for percutaneous repair of mitral valve are being developed. The CARILLON system is one of devices that is implanted into the coronary venous system, which enables tension of the mitral ring in order to improve coaptation of the leaflets. AIM: Echocardiographic analysis of the CARILLON system implantation efficacy evaluated directly and one month after implantation. METHODS: The study in included 9 patients, aged 58.56 +/- 6 years, with severe functional mitral regurgitation, who fulfilled the following echocardiographic criteria: large central jet l 4 cm(2) or l 20% of the left atrium area or wall-impinging eccentric jet reaching the pulmonary veins, vena contracta (VC) l 0.30 cm, effective regurgitant orifice area (ERO) l 0.2 cm(2), regurgitant volume (RV) l 30 ml or regurgitant fraction (RF) > 30%. Exclusion criteria were: concomitant severe tricuspid valve insufficiency, significant organic mitral valve pathology, chronic atrial fibrillation, foreign body in the coronary sinus, or thrombus in the left atrial appendage. The prerequsite for implanting the device was a significant reduction in the mitral regurgitation jet observed by transesophageal echo-cadiography (TEE), seen during the procedure. After one month, a transthoracic echocardiography (TTE) was performed to evaluate mitral regurgitation by analysing the same parameters assessed before implanting CARILLON to the coronary sinus. RESULTS: A significant improvement of VC after the procedure, in comparison to the value before the procedure (0.43 +/- 0.12 vs. 0.66 +/- 0.14 cm, p < 0.05), was observed. This improvement was lower one month after the implantation of the device (0.35 +/- 0.1 cm, p < 0.005). The ratio of the jet area to the left atrial area was reduced from 54.96 +/- 11.18% to 38.57 +/- 9.79% (p < 0.005) and sustained after a month at 36.33 +/- 10.15% (p < 0.005). Other echocardiographic parameters of evaluation of mitral regurgitation tended to improve, however the differences did not reach statistical significance. The ERO in subsequent studies was: 0.25 +/- 0.09 cm(2), 0.23 +/- 0.07 cm(2), and 0.24 +/- 0.07 cm(2), and RV decreased from 33.06 +/- 11.81 ml before the procedure, to 32.33 +/- 7.84 ml one month after the procedure. CONCLUSIONS: The CARILLON system implantation to the coronary venous system in patients with secondary mitral regurgitation can lead to the improvement of selected echocardiographic indices of mitral regurgitation.

The bi-phased course of electrophysiological response of isolated snail intestine on mechanical stimulation.

The transepithelial potential difference and changes of diameter of isolated snail intestine as index of its motility were studied in immersed bath in control conditions and after gentle stimulation by 60 seconds of washing of the intestinal lumen. Immediate depolarization and 20% augmentation of the lumen were observed during the stimulation. After stimulation, additional transient depolarization of the transepithelial potential difference and gradual diminution of intestine lumen back to control values over a period of 20 minutes occurred. The immediate reaction was greatly influenced by the presence of sodium or chloride ion transport inhibitors, however, the late phase of the response was not. It is hypothesized that changes of transepithelial electrogenic ion transport and of intestinal motility during the stimulation mirror the inflow of intestinal content and after completion of stimulation may be related to its storage.

Population Pharmacokinetic Model of Dexmedetomidine in a Heterogeneous Group of Patients.

Dexmedetomidine is a hepatically eliminated drug with sedative, anxiolytic, sympatholytic, and analgesic properties that has been increasingly used for various indications in the form of a short or continuous intravenous infusion. This study aimed to propose a population pharmacokinetic (PK) model of dexmedetomidine in a heterogeneous group of intensive care unit patients, incorporating 29 covariates potentially linked with dexmedetomidine PK. Data were collected from 70 patients aged between 0.25 and 88 years and treated with dexmedetomidine infusion for various durations at 1 of 4 medical centers. Statistical analysis was performed using a nonlinear mixed-effect model. Categorical and continuous covariates including demographic data, hemodynamic parameters, biochemical markers, and 11 single-nucleotide polymorphisms were tested. A 2-compartment model was used to describe dexmedetomidine PK. An allometric/isometric scaling was used to account for body weight difference in PK parameters, and the Hill equation was used to describe the maturation of clearance. Typical values of the central and peripheral volume of distribution and the systemic and distribution clearance for a theoretical adult patient were central volume of distribution = 22.50 L, peripheral volume of distribution = 86.1 L, systemic clearance = 34.7 L/h, and distribution clearance = 40.8 L/h. The CYP1A2 genetic polymorphism and noradrenaline administration were identified as significant covariates for clearance. A population PK model of dexmedetomidine was successfully developed. The proposed model is well calibrated to the observed data. The identified covariates account for <5% of interindividual variability and consequently are of low clinical significance for the purpose of dose adjustment.

Venous catheter microbiological monitoring. Necessity or a habit?

BACKGROUND: Usefulness and economic aspects of microbiological analysis of central venous catheter (CVC) tips in diagnosis of the catheter-related bloodstream infection (CRBSI). MATERIAL/METHODS: Retrospective study of an adult intensive care unit in a university hospital. Catheter removal was performed when the clinical state of the patient indicated that the catheter could be the source of infection or inflammation was observed at the puncture site. RESULTS: We microbiologically studied 238 CVC tips according to the Maki method and 723 blood samples from 120 septic patients treated during a 21-month period (32.9% of all patients treated in this time period). In 115 cases (48.4%), the tips were positive. Bacteremia was ascertained in 181 blood samples (24.1%), and 168 samples were collected at the time of CVC removal. In blood samples taken from 20 patients (3% of total blood samples), 25 cases of the same pathogens were isolated from CVC tips. In 12 cases, pathogens found in blood and CVC tips were also cultured in other places. In 13 cases (5.5% of tips), CVCs were the source of CRBSI. Positive predictive value (PPV) and negative predictive value reached 11% and 91%, respectively. The total cost of CVC tip monitoring was about 4000 euro. CONCLUSIONS: Our data support the hypothesis that colonization of CVC is rarely responsible for CRBSI. Relatively low PPV renders tips culture useless as a method of diagnosing CRBSI. Based on these results, the routine microbiological monitoring of CVC tips was discontinued to reduce the cost of treatment.

Toluene diisocyanate caused electrophysiological disturbances in the upper airways wall.

OBJECTIVES: Toluene diisocyanate (TDI) due to its widespread use in industry is one of the most common and well-known causes of occupational asthma and Reactive Airways Dysfunction Syndrome (RADS). In this study the impact of TDI on the electrophysiological properties of the airways wall, particularly on the mechanisms of absorption of sodium ions and chloride ions secretion was evaluated. MATERIALS AND METHODS: Isolated rabbit tracheal wall (from outbred stock animals) was mounted in an apparatus for electrophysiological experiments by means of Ussing method and was mechanically stimulated by the jet flux of specified fluid directed onto the mucosal surface of the tissue from a peristaltic pump. The measured parameters were: transepithelial potential difference under control conditions (PD, mV), after mechanical stimulation (dPD or physiological reaction of hyperpolarization, mV) and electric resistance (R, Omega cm2). When TDI (0.035 mM) was added to stimulation fluid, only the immediate reaction was identified and when it was added to incubation fluid and other experimental fluids, the late (post-incubation) reaction was determined. The experiments involving the inhibition of Na+ by amiloride and Cl- by bumetanide were also performed. RESULTS: A series of functional tests for 72 pieces of tracheal wall from 36 animals were performed. It has been shown that short-term exposure to TDI significantly changed the course of reactions to mechanical stimulation. Also after incubation in the presence of TDI, the reactions to mechanical stimulation were changed in relation to control conditions. CONCLUSIONS: The immediate reaction of the isolated rabbit tracheal wall after exposure to TDI depends on the duration of exposure and on the physiological condition of the tissue in respect of sodium and chloride ion transport.

[Does the coexistence of cancer have an influence on the course of sepsis]. / Czy wspólistniejaca choroba nowotworowa wplywa na ciezkosc przebiegu sepsy.

UNLABELLED: The guidelines for management of sepsis are constantly updated, nevertheless sepsis is still a difficult clinical problem, especially as its treatment often ends in failure. Hospitalized cancer patients diagnosed with sepsis are especially concerned, as sepsis death rate is significant in that group of patients. The aim of the study was to evaluate and compare cancer- and non-cancer patients diagnosed with sepsis. MATERIAL AND METHODS: The medical records of 56 patients diagnosed with sepsis from January 1. 2007 to August 1. 2008 were reviewed retrospectively. Patients were divided into two groups: 1 group--patients with sepsis and cancer (S+N), II group--patients with sepsis without cancer (S). The etiology of sepsis, primary infectious sources, chosen clinical and laboratory parameters and mortality were analysed. RESULTS: 56 patients were involved in the study. The mean age for S+N patients was higher than for group S (61.3 vs. 45.5 years; p = 0.005). The mean APACHE II score value at the day of admission for the whole population was 22.1 +/- 8.8 (8-45), for S+N group--25.3 +/- 10.3 (12-41) and for group S--21.2 +/- 8.3 (8-45) (p = 0.308). The estimated risk of hospital death was retrospectively 43.4%, 53.3% and 39.0%. Patients in group S+N required larger infusion of minimal noradrenaline doses than the other patients (p = 0.015). The mortality rate was 14.3% and was higher in group S+N than in group S (16.7 vs. 13.6%). Mortality was also significantly higher among patients with larger lactate blood concentration (death: 4.6 vs. survival: 1.9 mmol/l; p = 0.020) and greater base deficit (death: -6.79 vs. survival: -2.34 mmol/l; p = 0,0006). Patients of lower mean arterial pressure (60.8 vs. 75.9 mmHg; p = 0.007) and who required larger noradrenaline infusion (0.514 vs. 0.232 microg/kg/min; p = 0.0009) at the day of admission had a significantly higher risk of death. CONCLUSIONS: The analysis did not indicate evidently higher risk of more severe sepsis's course in cancer sepsis patients. However the severity of patients' general condition estimated by the APACHE II score and the mortality in this group of patients was higher (statistically insignificant results). Patients in group S+N required larger minimal doses of noradrenaline and larger infusion of colloid at the day of admission. The mortality was determined by the haemodynamic disturbance and the severity of general condition, rather than the cancer diagnosis per se.

Streptococcus constellatus as an aetiological factor of extensive neck phlegmon complicated by sepsis - case study.

Introduction. Streptococcus constellatus are opportunistic microorganisms. When immunocompromised patients with concomitant systemic diseases are infected with S.constellatus, the bacteria may cause sepsis. Case study. A patient was admitted to hospital due to septic shock and multi-organ dysfunction in the course of neck phlegmon. The microbiological system identified S. constellatus in the patient who worked as a dog groomer. These facts confirmed that this aetiological factor may have caused such a serious infection because S. constellatus is a bacterial species found in dogs. It is most likely that the bacteria colonised the patient. Zoonotic transmission of microorganisms is particularly important for the development of infections in dogs and humans. Knowledge about how to treat deep cervical infections is necessary in the daily practice of a maxillofacial surgeon. The right antibiotic can applied only when the strain causing the infection has been identified.

Percutaneous valve repair for mitral regurgitation using the Carillon Mitral Contour System. Description of the method and case report.

Mitral regurgitation may result from left ventricular dilatation and cause progression of heart failure. Percutaneous techniques for mitral valve repair are under development. Techniques utilizing a trans-coronary venous approach exploit the anatomical relationship between the mitral annulus and the venous system of the heart. The coronary sinus, great cardiac vein and the origin of the anterior interventricular vein surround the posterior mitral annulus. This enables percutaneous approaches to annuloplasty for mitral regurgitation. Devices can be implanted into the coronary veins that modify the shape and size of the mitral annulus. We present a case of ischaemic mitral regurgitation successfully treated by use of a percutaneous approach, the Carillon Mitral Contour System. Significant reduction of the mitral regurgitation jet was observed. The patient was discharged 4 days after the procedure. During the follow-up visits, the patient showed an improved general condition and increased exercise capacity. Procedural steps are shown in detail and the current status of the coronary sinus based technique is discussed. Percutaneous techniques for mitral valve repair may be an attractive alternative to cardiac surgery in heart failure patients with secondary mitral regurgitation. The Carillon Mitral Contour System is under ongoing clinical evaluation in the AMADEUS trial.

[Tracheotomy as a bedside procedure in the Intensive Care Unit: is it safe?]. / Czy tracheotomia wykonywana na oddziale Intensywnej Opieki Medycznej (IOM) jest procedura bezpieczna?

BACKGROUND: The authors would like to present the problem of performing bedside tracheotomy in the Intensive Care Unit. The tracheotomy have been done in the highly specific group in poor or fatal general condition, so the complication rate according to the general status of the patients is discussed. MATERIAL: 92 patients were treated with tracheotomy between I 2003-XII 2005 and in this number 13 complications occurred. The general status of the patients (shock, stroke, sepsis, pneumonia, hypoalbuminemy) in the time of procedure was taken into consideration. RESULTS: In early complications dominated the bleeding--in 7 patients (7.9%) and wound infections--in 4 patients. Tracheal strictures, the only late complication found in our group, were stated during the follow up period in 2 patients (1.1%). The time of performing the tracheotomy i.e. day of the intubation (range from 0-13; mean--5.7) and day of the decaniulation (range from 3-65; mean--16) were analyzed. CONCLUSION: Tracheotomy performed in the Intensive Care Unit as a bedside procedure is safe, quick and effective. Complication rate in the group of patients in poor general condition is comparable both to the average population and to the percutaneous technique.

Comparison of the influence of halothane and isoflurane on airway transepithelial potential difference.

Bidirectional transport of Na+ and Cl- ions by the epithelium controls production and composition of airway surface liquid and airway transepithelial potential difference and in these ways supports mucociliary transport. Volatile anesthetics are able to inhibit epithelial ion transport processes when applied at high concentration and have been suggested to elicit depression of airway clearance and both these effects could be involved in postoperative pulmonary complications. The goal of these studies was to reveal possible influence of halothane and isoflurane at lower concentrations on electrogenic ion transport in airway epithelium. These studies were performed on the isolated rabbit tracheal wall mounted in the Ussing chamber. The reaction of the preparation to the gentle mechanical stimulation performed as a jet flux was examined without or in the presence of anesthetics at concentration equivalent to 0.5 minimal anesthetic concentration of volatile anesthetics in pulmonary alveoli (MAC), 1 MAC, 2 MAC, 5 MAC and 10 MAC. The volatile anesthetics at concentrations equivalent to 5 and 10 MAC affected airway transepithelial potential difference and influenced hyperpolarization or depolarization reactions which occurred after mechanical stimulation. The above effects were present when Na+ transport was inhibited by amiloride. The disturbed epithelial Cl- transport may be proposed as an explanation of the action of volatile anesthetics on electrophysiological parameters of the isolated tracheal wall although the influence of anesthetics on tachykinin secretion from C-fiber endings, which are present in the preparation, should also be taken into consideration. The long-lasting action (tens of minutes) of volatile anesthetics on the isolated tracheal wall should be also studied in the future as a model of airway reaction to prolonged volatile anesthesia.

[Central venous catheter as a reason of bleeding after tracheotomy]. / Cewnik kontaktu centralnego przyczyna krwawienia po tracheotomii.

Tracheotomy as an operation may be connected with many complications. One of them is intra- or postoperative bleeding. A lot of reasons of such bleeding is well known, but we describe a case of bleeding caused by central venous catheter which was inserted into external jugular vein, but dislocated into anterior jugular vein and destructed it's wall. The bleeding observed after tracheotomy was firstly counted as an effect of coagulation defect connected with heparin supply. When few days after tracheotomy the tip of the catheter was seen in the tracheotomy, patient was quickly operated--the destructed anterior jugular vein and external jugular vein were ligated and the central venous catheter was removed.

An acid-base disorders analysis with the use of the Stewart approach in patients with sepsis treated in an intensive care unit.

BACKGROUND: Patients with sepsis admitted to the intensive care unit often present with acid-base disorders. As the traditional interpretation might be clinically misleading, an alternative approach described by Stewart may allow one to quantify the individual components of acid-base abnormalities and provide an insight into their pathogenesis. The aim of our study was to compare the traditional and Stewart approaches in the analysis of acid-base disturbance. METHODS: We analyzed arterial blood gases (ABG) taken from 43 ICU septic patients from admission to discharge categorising them according to SBE values. The traditional concept analysis was compared with the physicochemical approach using the Stewart equations. RESULTS: 990 ABGs were analysed. In the SBE < -2 mEq L⁻¹ group, hyperlactatemia was observed in 34.7% ABG, hypoalbuminemia in 100% and SIG acidosis in 42% ABG. Moreover, a Cl/Na ratio > 0.75 was present in 96.9% ABG. In the normal range SBE group, elevated lactates were present in 21.3% ABG, SIG acidosis in 14.9%, elevated Cl/Na ratio in 98.4% and hypoalbuminemia in all 324 ABG. In the metabolic alkalosis group (SBE > +2 mEq L⁻¹), hyperlactatemia was observed in 18.4% ABG, SIG acidosis in 5% ABG, Cl/Na ratio> 0.75 in 88.8%, while 99.1% samples revealed hypoalbuminemia. CONCLUSION: The use of the Stewart model may improve our understanding of the underlying pathophysiological mechanism and the true etiology of the derangements of acid-base disorders. Indeed, it proves that patients may suffer from mixed arterial blood gas disorders hidden under normal values of SBE and pH.