Early oral hydration in patients with high enterocutaneous fistula.

INTRODUCTION: Enterocutaneous fistula is defined as an abnormal connection between the gastrointestinal tract and the skin. In addition to the early recognition and treatment of sepsis, nutritional support, wound management, the adequate replacement of lost fluids with a properly set and timely rehydration treatment, together with the control of fistula production represent the first steps in treatment management. MATERIAL AND METHODS: The authors present an overview of oral rehydration therapy, describing the properties and effects of individual solutions on fistula. The absorption of fluids and electrolytes into the gastrointestinal tract is performed by the group of sodium-dependent glucose cotransporters (sodium-glucose linked transporter, SGLT1). DISCUSSION: The water and electrolyte absorption mechanisms described in the article can be used in the treatment of a patient with a high fistula. The amount of administered hypotonic fluids (water, tea) should not exceed 500 ml/day. The remaining volume, depending on fistula loss, must be supplemented with isoosmolar fluids. With a good tolerance of oral rehydration solutions and compliance with the other steps of treatment, it is possible to remain on oral intake during the entire duration of treatment without the need to prohibit it completely, thus improving the patient's overall comfort. CONCLUSION: Reducing the intake of hypotonic fluids (tap water, tea) and administering an isotonic solution help to reduce the production of the fistula, thereby contributing to its spontaneous closure.

Association between pulmonary embolism and COVID-19 disease.

OBJECTIVES: The current retrospective study focused on evaluation of the relationship between pulmonary embolism during COVID-19 pandemic and demographic, presenting symptoms, comorbidities and laboratory results in patients who underwent CT angiography of the pulmonary arteries. METHODS: The study enrolled all adult patients with suspected acute pulmonary embolism (PE) who underwent computed tomography pulmonary angiography (CTPA) between March 1, 2020, and April 30, 2022, during the SARS-CoV-2 pandemic. 1698 CTPAs were reviewed and various data were collected. Based on examination results, patients were divided into 4 groups: a group with positive PE and a group with negative PE for both COVID-19 and non-COVID-19 patients. RESULTS: When comparing different predictors of COVID-19 patients and non-COVID-19 patients we noticed lower probability of PE in female gender (OR 0.77, 95% CI: 0.60-1.00, p = 0.052) and in chronic obstructive pulmonary disease (COPD) patients (OR 0.6, 95% CI: 0.38-0.90, p = 0.017). Higher probability of PE was in cases of older age (OR 1.02, 95% CI: 1.01-1.02, p < 0.001), increased heart rate (OR 1.01, 95% CI: 1.01-1.02, p < 0.001) and increased D-dimer levels (OR 1.03, 95% CI: 1.02-1.04, p < 0.001). CONCLUSION: Considering predictors of PE there was a significantly lower risk of PE in the female gender and COPD, and a higher risk with increasing age, heart rate, and D-dimer levels.

Clostridium septicum foot gangrene associated with colorectal cancer.

INTRODUCTION: Since the second half of the 20th century, an association between the occurrence of Clostridium septicum and Streptococcus gallolyticus infections in patients with colorectal cancer has been described in specialist literature. Infections are manifested by bacteremia, septic embolism, cellulitis, myonecrosis, and gas gangrene of the limbs. MATERIAL AND METHODS: The authors present a case of a rare association between lower limb gangrene caused by the septic embolization of a Clostridium septicum infection and malignancy of colon ascendens in a polymorbid patient. Gangrene of the lower limb led to septic shock requiring acute amputation treatment. After managing the acute condition, the patient was operated on for a malignant colon tumour. DISCUSSION: The process of carcinogenesis often takes years and is almost asymptomatic. The occurrence of S. bovis/S. equinus (SBSEC) and C. septicum bacteremia, respectively, is relatively rare, but their presence is often associated with the occurrence of malignancy, most often of the lower gastrointestinal tract. This paraneoplastic symptom may be the first manifestation of a malignant disease. The effect of exotoxins can lead to sepsis or even septic shock with a mortality of 48-56%. CONCLUSION: Clostridium septicum and Streptococcus gallolyticus infections are rare in clinical practice. However, their presence can be a first paraneoplastic symptom, and therefore the doctor should look for a possible oncological disease when they are detected. The main diagnostic methods include colonoscopy and imaging, especially CT scan.

Post-operative behavioural disorders in paediatric anaesthesia caused by anaesthetics and sedatives.

Neurotoxicity of anaesthetics have become one of the most discussed problems in paediatric anaesthesiology. The experimental studies on animal models have shown that the anaesthetics used in general anaesthesia should have an influence on neurodegenerative processes, neuroapoptosis and irregulated death of the neuronal cells.Because of this fact, scientists are trying to discover the possibilities of how to minimize the adverse effects of anaesthesia and revise the other alternatives of prevention of anaesthesia-induced maladaptive behavioural disorders (Tab. 1, Fig. 1, Ref. 21). Keywords: neurotoxicity of anaesthetics, maladaptive behavioural disorders, mechanism of neurotoxicity, post-anaesthetic behavioural changes in children, future of paediatric anaesthesiology.

Jejunal diverticulosis: A rare cause of massive bleeding.

INTRODUCTION: Jejunal diverticulosis is a rare diagnosis that occurs mainly in old age, more often in men than in women. It is usually an incidental diagnosis of unclear aethtiology. In some cases, visceral myopathy can also be the cause. It is most often manifested by abdominal pain and bleeding. Bleeding from the small intestinal diverticula represents only 0.6-5% of all small intestinal bleeding. CASE REPORT: The authors describe the case of a 66-year-old man with massive gastrointestinal bleeding who did not respond to conservative hemostyptic treatment. Following negative gastrofibroscopic and colonoscopic examinations, an angioCT examination was indicated, which revealed a source of bleeding in the jejunal diverticula. The patient was indicated for surgical treatment. The extent of bleeding was determined by perioperative enteroscopy and subsequently, the affected jejunal segment was segmentally resected with a primary anastomosis. CONCLUSION: Bleeding from the jejunal diverticula is a very rare diagnosis, which poses challenges in the diagnostic process in particular. Capsule enteroscopy plays an important role in the diagnosis, as well as CT angiography and scintigraphy in the event of massive bleeding. In addition to conservative treatment, the embolization of a bleeding vessel may subsequently be used in therapy. In indicated cases, surgical resection treatment is also possible.

Surgical treatment of severe dumping syndrome.

Dumping syndrome is a common post-operative complication following gastric surgery. Clinically, severe dumping can be a serious medical condition with a negative impact on the patient's life. In our case report, we present a case of refractory dumping syndrome which developed after laparoscopic subtotal gastrectomy with gastrojejunoanastomosis due to massive gastroptosis with stomach evacuation problems. Conservative gastroenterology treatment was not successful. Due to the progression of weight loss and life-threatening hypoglycaemia, the decision for surgical treatment was made. After the corrective gastro-duodenal and jejuno-jejunal anastomoses, all clinical symptoms resolved completely. With regard to the presented case, we discuss the common treatment options for dumping syndrome: the standard recommendations for dietary habits, pharmacological treatment and finally the surgery and its pitfalls. Due to the absence of randomized trials and guidelines, every patient should be treated in a personalized way.

A multidisciplinary approach to the management of descending necrotizing mediastinitis - case series.

OBJECTIVES: Descending necrotizing mediastinitis (DNM) is a severe potentially fatal disease of the mediastinum which spreads downwards from oropharyngeal region. Mortality varies from 11 to 40%. There is agreement on the importance of early diagnosis, aggressive surgical treatment and the need for a multidisciplinary approach. DESIGN: Retrospective study of series of patient treated for DNM regarding multidisciplinary approach and surgical treatment. PATIENTS AND METHODS: Sixteen patients that were surgically treated for DNM from 2008 to 2017 at our hospital were consecutively enrolled in observational descriptive study. RESULTS: Twelve patients had disease localised above tracheal bifurcation level. Nine of them underwent transcervical drainage, three patients underwent more extensive treatment. Four patients with disease spread below the treacheal bifurcation level were treated with transcervical drainage in combination with posterolateral thoracotomy or videothoracoscopy. Three patients underwent videothoracoscopy - two of them as primary surgical treatment with need of one reoperation - contralateral videothoracoscopy. The third patient was initially treated with a transcervical approach and videothoracoscopy was indicated as a reoperation because of the progression of the disease. One patient died (mortality 6.25%). CONCLUSION: In management of descending necrotizing mediastinitis, early diagnosis, aggressive surgical treatment and use of broad-spectrum antibiotics and nowadays also multidisciplinary approach are crucial. Transcervical drainage combined with posterolateral thoracotomy or videothoracoscopy were used with good results.

Iatrogenic perforation of hypopharynx as a cause of severe descending necrotizing mediastinitis: A case report.

The authors present a case report of severe descending necrotizing mediastinitis (DNM) etiologically of unrecognized traumatic endotracheal intubation with hypopharynx-esophageal junction perforation. Patient was treated inadequately for seven days in local hospital what was the cause of sepsis progression into the septic shock with multiorgan dysfunction syndrome. Patient was transferred to specialized hospital and was immediately operated in general anaesthesia - combined transcervical approach and lateral thoracotomy was used for mediastinal drainage and debridement. Combination of appropriate conventional and surgical therapy led to reversing of the unfavorable situation.

Some quantitative EEG features in default mode resting state network under general anaesthesia.

OBJECTIVES: The default mode resting state network (DMRSN) constitutes a circuit which is active in conditions when the subject is at rest. We tested the hypothesis that its function will be altered during unconsciousness. METHODS: Changes in the mean squared coherences in five conventional frequency bands (delta to gamma) in DMRSN during general anaesthesia (GA) were investigated in 39 patients. They were compared with the normal EEG of 86 alert subjects, severely abnormal EEG of 112 patients with dementia and/or encephalopathy, and the mathematical model of brain death. RESULTS: Anaesthetised patients showed significant decrease in the gamma coherence in the posterior area of the DMRSN compared to both the control group and the patients with dementia and/or encephalopathy. Among the anaesthetized patients 21 had a clear burst suppression pattern with prolonged epochs of suppression in EEG. In suppressed EEG segment the differences between the connections of the anterior to posterior parts and connections between the posterior parts of the DMRSN were almost lost. However, they still showed highly significant differences in most items when compared with coherences in the mathematical model of brain death. CONCLUSION: The functional connectivity in the DMRSN could be a reliable and robust method for assessing the depth of anaesthesia and maybe also disorders of consciousness in general. The mean squared coherences in the gamma frequency band indicated the highest sensitivity for the depth of unconsciousness. The measure is not dependent on the diffused slowing in dementia or encephalopathy patients as long as they remain in a full consciousness.

Prefrontal left--dominant hemisphere--gamma and delta oscillators in general anaesthesia with volatile anaesthetics during open thoracic surgery.

OBJECTIVES: The main objective was to indicate sufficient general anaesthesia (GA) inhibition for negative experience rejection in GA. PATIENTS AND METHODS: We investigated the group of patients (n = 17, mean age 63.59 years, 9 male--65.78 years, 8 female - 61.13 years) during GA in open thorax surgery and analyzed EEG signal by power spectrum (pEEG) delta (DR), and gamma rhythms (GR). EEG was performed: OPO - the day before surgery and in surgery phases OP1-OP5 during GA. Particular GA phases: OP1 = after pre- medication, OP2 = surgery onset, OP3 = surgery with one-side lung ventilation, OP4 = end of surgery, both sides ventilation, OP5 = end of GA. pEEG registering in the left frontal region Fp1-A1 montage in 17 right handed persons. RESULTS: Mean DR power in OP2 phase is significantly higher than in phase OP5 and mean DR power in OP3 is higher than in OP5. One-lung ventilation did not change minimal alveolar concentration and gases should not accelerate decrease in mean DR power. Higher mean value of GR power in OPO than in OP3 was statistically significant. Mean GR power in OP3 is statistically significantly lower than in OP4 correlating with the same gases concentration in OP3 and OP4. CONCLUSION: Our results showed DR power decreased since OP2 till the end of GA it means inhibition represented by power DR fluently decreasing is sufficient for GA depth. GR power decay near the working memory could reduce conscious cognition and unpleasant explicit experience in GA.

Incidence of skeletal muscle disorders after statins' treatment: consequences in clinical and EMG picture.

OBJECTIVES: The goal of this clinical trial was to determine the incidence of undesirable side effects, and to ascertain any occurrence of genetic polymorphisms. MATERIAL AND METHODS: Clinically, we looked for manifestations of a benign myositis and of serious rhabdomyolysis. We observed a group 198 patients treated with statins, primarially fluvastatin and rosuvastatin. There were 126 (mean age = 58.3 ± 4.1; male 91, mean age = 57.4 ± 5.9; female 35, mean age = 60.5 ± 6.5) patients in a subgroup where we administered rosuvastatin. Undesirable muscular signs and symptoms were present in 32 patients (25.39%). In 11 (8.73% of the total 126) CK level increased maximally to 4 times ULN, in 6 (4.7%) statins were excluded because of very intense subjective suffering. CK levels 2-5 times ULN were present in 9 (7.14%). CK blood levels over 10 times ULN or higher indicated statins exclusion in 2 (1.58%). Increased levels of the further muscular enzyme AST by 5 times ULN were present in 16 (12.69%), up to 10 times ULN in 2 (1.58%), and over 10 times ULN also in 2 (1.58%). RESULTS: We observed rhabdomyolysis in 6 patients (3.03% of the total 198 patients group) using other types of statins (three of them undergo chronic hemodialysis). In this group we performed molecular-genetic analysis of the following proteins relating to statin myopathy: SLCO1B1(388AA/AG-521TT) - (discovered polymorphism in 1 patient), further cytochroms Cyp 2C9 (in 1 patient), 2C8 (in 1 patient), Cyp SA/4 (non discovered positivity) and finally UGT1A1*2B (discovered in 2 patients). CONCLUSIONS: In the group of patients treated by rosuvastatin, we discovered not one case of rhabdomyolysis. In each patient with rhabdomyolysis (brown urine discoloration, mal-odorous urine, painful muscle cramps, muscle weakness, fatigue) at least one polymorphism of "statins´ genes" was present.

Cerebral malaria complicated with coma, multiorgan failure and psychosocial sequellae observed among non-immune travelers to Benin, Sudan and Madagascar.

OBJECTIVE: Severe malaria represents less than 10% of all malaria cases and is associated with significant mortality. The aim of this case series was to review severe malaria cases in travelers within the last 10 years in Slovakia. METHODS: All cases of severe malaria in travelers reported within last 10 years from the Inpatient Department in Slovakia to the Slovak Tropical Institute (STI) are reviewed. Only those traveling as tourist to Sub-Saharan Africa were included. RESULTS: During the last 10 years, eight (n=8) cases of cerebral malaria were reported, of which only one died (12.5%). Seven of all 8 cases had deep coma (87.5%), 4 (50%) required ventilator support, 4 (50%) required dialysis, 5 (62.5%) had liver failure and 6 (75%) had severe acidosis. CONCLUSION: Severe malarial cases were rarely detected among travelers returning to Slovakia within last 10 years. In survivors usually no sequellae remained. One patient treated with quinine alone died.

The comparison of general anaesthesia using the bispectral analysis (BIS) and spinal anaesthesia in terms of the one-day health care for haemorrhoid surgery using the HAL-RAR method.

OBJECTIVES: The gradual advancement of one-day surgery and conjoint ambulatory anaesthesia results from possibilities to execute mini-invasive surgeries. Such surgeries offer great benefits to the patient due to faster reconvalescence and less pain as well as faster return to normal life. The HAL-RAR method for haemorrhoid surgery, introduced as early as in 1995 by Dr. Morigan in Japan. DESIGN AND SETTING: The goal of our study including 137 patients was research of effects of the spinal and general anaesthesia while monitoring the Bispectral Index (BIS) during the surgery. We focused mainly on the need of postoperative analgesia and possibility to discharge patient to home care after the surgery with the above mentioned type of anaesthesia. BIS helped us to monitor the sufficiency of anaesthesia and anaesthetics dosage regulation that was reflected in earlier awakening and faster reconvalescence, as well as saving anaesthetics. RESULTS: The length of surgery was not affected by the particular type of anaesthetic procedures (25.7 minutes for the general anaesthesia and 30.2 minutes for the spinal anaesthesia). The need for postoperative analgesia was necessary for the period of 240.0 minutes after the completion of surgery for the general anaesthesia and 313.0 minutes for the spinal anaesthesia after the administration of anaesthetics intrathecally. CONCLUSIONS: BIS is a processed EEG parameter measuring the hypnotic effect of hypnotics and sedatives in brain. BIS helps to reduce the use of anaesthetics during anaesthesia. Our results are promising and we continue in the study, monitoring also other possible parameters.

Acute consciousness disorders in intensive care medicine - value of its grading for prognostic conclusion.

OBJECTIVES: To understand consciousness we have to understand the mechanism of its function, which is to effectively organize sensory inputs from our environment. Consciousness is the basic, essential outcome of the process of organizing these sensory inputs, resulting in cognitive, mental, emotional, executive, instinctual or other marginally aware states. This reciprocal process of the CNS implies that organization is an act, which precedes consciousness, i.e. preconscious function. Most scientific explanations portray consciousness as an "emergent property" of classical computer-like activities in the brains neural networks. Doctors at ICU work daily with patients with altered human consciousness. Therefore, they must recognize and manage it skilfully and use adequate approaches for definite solutions. MATERIAL AND METHODS: We observed a series of patients with traumatic and non traumatic brain injuries admitted to the ICU. The quality of life of these patients during the course of intensive care was very elementary and the final outcome GCS (oGCS) for future life was defined as a comatose state or apallic state, very rarely was it restored to premorbid condition as far as lucidity, attention, cognition, and executive functions. RESULTS: We found that a significant oGCS increase in relation to condition at admission or intake GCS (iGCS) in the group with 184 patients total (p<0.00001), in cardio-pulmonary resuscitation (CPR), traumatic brain injury (TBI) subgroups (p<0.00001) and in spontaneous haemorrhage (SH) (p<0.05) represents the only basic prerequisite for further improvement. It is not easy to find good therapeutic approaches after traumatic and non traumatic brain injury. A statistically significant oGCS increase in relation to iGCS due to quite intense medical care and keeping disclosed the state of unconsciousness with further probable evolution through the following possible ways: death in fluent comatose state, delirium and awakening, delirium ending in death, direct awakening from comatose state. Therefore significantly increased oGCS is the only basic prerequisite for pragmatically optimal "quality of life" in the course of later life. CONCLUSION: We raise general questions for both scientists and clinicians that will assist in their efforts to understand the basic endogenous conscious biological processes, their pathological changes and the links between them.

Ischemic tolerance: the mechanisms of neuroprotective strategy.

The phenomenon of ischemic tolerance perfectly describes this quote "What does not kill you makes you stronger." Ischemic pre- or postconditioning is actually the strongest known procedure to prevent or reverse neurodegeneration. It works specifically in sensitive vulnerable neuronal populations, which are represented by pyramidal neurons in the hippocampal CA1 region. However, tolerance is effective in other brain cell populations as well. Although, its nomenclature is "ischemic" tolerance, the tolerant phenotype can also be induced by other stimuli that lead to delayed neuronal death (intoxication). Moreover, the recent data have proven that this phenomenon is not limited to application of sublethal stimuli before the lethal stress but reversed arrangement of events, sublethal stress after lethal insult, is rather equally effective. A very important term is called "cross conditioning." Cross conditioning is the capability of one stressor to induce tolerance against another. So, since pre- or post-conditioners can be used plenty of harmful stimuli, hypo- or hyperthermia and some physiological compounds, such as norepinephrine, bradykinin. Delayed neuronal death is the slow development of postischemic neurodegeneration. This allows an opportunity for a great therapeutic window of 2-3 days to reverse the cellular death process. Moreover, it seems that the mechanisms of ischemic tolerance-delayed postconditioning could be used not only after ischemia but also in some other processes leading to apoptosis.

Delirium and postoperative cognitive dysfunction after general anesthesia.

BACKGROUND: General anesthesia is characterized by unconsciousness, analgesia, muscle relaxation, and depression of reflexes, generally in response to the administration of chemical agents that induce reversible unconsciousness. Study of the cognitive neuroscientific basis of general anesthesia involves evaluation of the effect of anesthetic agents on consciousness and the brain mechanisms underlying cognitive function. Central nervous system dysfunction after anesthesia and/or surgery can occur at any age but is a particular issue for elderly patients. Studies of delirium and postoperative cognitive dysfunction have been published in many countries since the end of the last century. We present a discussion of delirium disorders and a review of the literature. CASE REPORT: We also present case reports for 2 patients who underwent general surgery for epilepsy. The first patient experienced postoperative visual illusions, hallucination, and time and space disorientation. The second patient experienced a postoperative zombie-like delirium state. The status of both patients was improved in response to treatment with methylprednisolone. The first patient also received amantadine sulfate, and the second patient received antiepileptic drugs. CONCLUSIONS: The brain is the main target organ for anesthetic and adjuvant drugs, and age-associated changes in the brain have important implications with respect to general anesthesia. Anesthetists and surgeons have suspected for many years that some patients suffer a postoperative decline in cognitive function. The condition generally has a good outcome because oxidative nerve cell derangements and neurotransmitter imbalances are transient.

Serum neuron specific enolase and malondialdehyde in patients after out-of-hospital cardiac arrest.

BACKGROUND: Sudden cardiac arrest (CA) is a leading cause of death in Europe. The victims of CA need immediate cardiopulmonary resuscitation (CPR). Patients resuscitated due to CA have high mortality rate. Prognostic evaluation based on clinical observation is uncertain and would benefit from the use of biochemical markers of hypoxic brain damage. Multiple factors of brain origin can be measured in blood. OBJECTIVE: The purpose of this study was to validate the use of the serum neuron-specific enolase (NSE) and malondialdehyde (MDA) concentrations for predicting in-hospital death, after resuscitation from out-of-hospital CA. Neuronal damage and impairment of the blood-brain-barrier integrity can be detected by the release of NSE into cerebrospinal fluid and eventually into the blood. MDA represents a product of lipid peroxide decomposition reactions. METHODS: In a prospective study of 35 consecutive survivors of out-of-hospital CA, serum samples were obtained within 24, 72 and 168 h after the CA. NSE and MDA concentrations were measured, relationship between concentration in group of in-hospital death and survived patients were examined. Results There was a significant difference in NSE concentration between survivors and dead group on 1st day of measurement, marginally significant difference on 3rd day and no statistically significant difference in NSE on 7th day of measurement. There was marginally significant difference in MDA levels in both groups in all days of measurements. CONCLUSION: Estimation serum concentrations of NSE but not MDA seems to be a predictor of fate of patients after CA. The exact nature of oxidative stress can only be resolved by further studies.