Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock.

PURPOSE: The echocardiography parameters may predict the maintenance of sinus rhythm after cardioversion of a supraventricular arrhythmia (SVA). MATERIALS AND METHODS: Patients in septic shock with onset of an SVA, normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of <1.0 µg/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1 h and 4 h post cardioversion on an infusion of propafenone or amiodarone. RESULTS: Cardioversion was achieved in 96% of the 209 patients within a median time of 6(1.8-15.6)h, 134(64.1%) patients experienced at least one SVA recurrence after cardioversion. At 4 h the left atrial emptying fraction (LA_EF, cut-off 38.4%, AUC 0.69,p˂0.001), and transmitral A wave velocity-time-integral (Avti, cut-off 6.8 cm, AUC 0.65,p = 0.001) showed as limited predictors of a single arrhythmia recurrence. The LA_EF 44(36,49)%, (p = 0.005) and the Avti 8.65(7.13,9.50)cm, (p < 0.001) were associated with sustained sinus rhythm and decreased proportionally to increasing numbers of arrhythmia recurrences (p < 0.001 and p = 0.007, respectively). The enlarged left atrial end-systolic diameter at the arrhythmia onset (p = 0.04) and elevated systolic pulmonary artery pressure at 4 h (p = 0.007) were weak predictors of multiple(˃3) recurrences. CONCLUSION: The LA_EF and Avti are related to arrhythmia recurrences post-cardioversion suggesting potential guidance to the choice between rhythm and rate control strategies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03029169, registered on 24th of January 2017.

The effect of smoking and elderly age on digital replantation - a multivariate analysis.

INTRODUCTION: It is often questioned whether to perform replantation or revision amputation for amputation injuries in elderly patients and smokers. According to the current indication criteria, neither old age nor smoking in the absence of other risk factors are considered to be risk factors for replantation failure. However, many microsurgeons still may make the decision not to perform digital replantation based solely on these factors. MATERIAL AND METHODS: In order to evaluate the influence of both factors, we provided univariate and multivariate analyses of patients who underwent replantation at our centre during a 10-year period. We divided patients in two groups according to age (< and ≥ 60 years) and smoking status. RESULTS: In the univariate analysis, there were no differences in immediate results between the two age groups. In the multivariate analysis, no statistical difference was found in neither long-term nor short-term results between the two age groups and between smokers and non-smokers. CONCLUSION: Smoking and age should not be considered the only risk factors when deciding whether to perform digital replantation.

Is the process of withdrawal of life-sustaining measures in the intensive care unit different for deceased organ donors compared with other dying patients? A secondary analysis of prospectively collected data.

OBJECTIVE: To investigate whether observable differences exist between patterns of withdrawal of life-sustaining measures (WLSM) for patients eligible for donation after circulatory death (DCD) in whom donation was attempted compared with those patients in whom no donation attempts were made. SETTING: Adult intensive care units from 20 centres in Canada, the Czech Republic and the Netherlands. DESIGN: Secondary analysis of quantitative data collected as part of a large, prospective, cohort study (the Death Prediction and Physiology after Removal of Therapy study). PARTICIPANTS: Patients ≥18 years of age who died after a controlled WLSM in an intensive care unit. Patients were classified as not DCD eligible, DCD eligible with DCD attempted or DCD eligible but DCD was not attempted. PRIMARY AND SECONDARY OUTCOME MEASURES: The process of WLSM (timing and type and, if applicable, dosages of measures withdrawn, dosages of analgesics/sedatives) was compared between groups. RESULTS: Of the 635 patients analysed, 85% had either cardiovascular support stopped or were extubated immediately on WLSM. Of the DCD eligible patients, more were immediately extubated at the initiation of WLSM when DCD was attempted compared with when DCD was not attempted (95% vs 61%, p<0.0001). Initiation of WLSM with the immediate cessation of cardiovascular measures or early extubation was associated with earlier time to death, even after adjusting for confounders (OR 2.94, 95% CI 1.39 to 6.23, at 30 min). Other than in a few patients who received propofol, analgesic and sedative dosing after WLSM between DCD attempted and DCD eligible but not attempted patients was not significantly different. All patients died. CONCLUSIONS: Patients in whom DCD is attempted may receive a different process of WLSM. This highlights the need for a standardised and transparent process for end-of-life care across the spectrum of critically ill patients and potential organ donors.

[Outcomes and Complications of Surgical Treatment for LSS at 1-Year Follow-up - Prospective Study]. / Výsledky a komplikace po operacním resení LSS v horizontu jednoho roku ­ prospektivní studie.

PURPOSE OF THE STUDY Lumbar spinal stenosis (LSS) is a serious and fairly frequent disorder with prevalence increasing with age which often results in a disability. The surgical procedures are often very risky due to the greater age of patients with severe stenosis and their comorbidities. The study aimed to assess the functional outcomes and complications in patients who underwent surgical treatment for LSS at one year postoperatively and to identify the differences in the functional outcomes, if any, in dependence on the number of operated segments. MATERIAL AND METHODS It was a prospective study which included 33 patients who underwent surgery at the authors department from 1 November 2015 to 1 October 2016 for LSS, the mean age of patients was 69.5 (43-83) years. The surgery was indicated based on the clinical examination, radiography and MR imaging and consisted in posterior decompression with or without stabilisation and fusion. Pre- and post-operatively, a neurological examination and evaluation of patient difficulties were performed by: VAS - particularly for low back pain (VAS-LB) and lower limb pain (VAS-LL), Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSSQ). The evaluation was done at a half year and one year after the surgery. The authors made comparisons in dependence on the number of treated segments (1-2, 3-5 and Th-S stabilisation). RESULTS A significant improvement of all the followed-up parameters was reported at one year postoperatively. At one year after the surgery, the VAS-LB score showed a decrease by 2.39 (p = 0.001), the VAS-LL by 3.26 (p < 0.001), while a decrease by 2 or more points is considered clinically significant. When evaluating the SSSQ questionnaire, a decrease in subjective difficulties (SSSQ-S) was by 0.89 (p < 0.001), in physical function (SSSQ-F) by 0.87 (p < 0.001). In this questionnaire, the satisfaction rate with the surgery was 2 - i.e. somewhat satisfied. Altogether 76% of patients were very or somewhat satisfied, no one was very dissatisfied. When evaluating the ODI, an improvement by 20.6% (p < 0.001) was reported. The authors identified neither any significant differences in the outcomes at a one-year follow-up in dependence on the length of stabilisation, nor any significant differences between the six-months and one-year follow-up. Intraoperative complications occurred in 18%, early postoperative complications in 6% of patients. The ASD developed in 9% within one year. DISCUSSION The authors confirmed a significant improvement of the followed-up parameters (VAS-LB, VAS-LL, SSSQ, ODI) which corresponds with recent literature. The decrease in VAS and ODI in the authors study is more marked than the outcomes stated in literature. The authors outcomes clearly show that there is no correlation with the length of stabilisation and the number of decompressed segments. Conversely, the rate of complications was higher in this group than the rates stated in literature, but majority of complications had no consequences for the patients. CONCLUSIONS In the group of patients with a one-year follow-up the authors confirmed that surgical procedures will result in reduced subjective difficulties of patients, reduced pain and improvement of physical function. A significant improvement of all the followed-up parameters was reported. The authors did not confirm the correlation between the postoperative improvement and the number of treated segments. Key words:lumbar spinal stenosis, quality of life, post-operative outcomes, complications.

Propafenone for supraventricular arrhythmias in septic shock-Comparison to amiodarone and metoprolol.

PURPOSE: The occurence of supraventricular arrhythmias associate with an unfavourable prognosis in septic shock. Propafenone could be a feasible antiarrhythmic. MATERIALS AND METHODS: Patients collected over a period of 24months were divided into the three groups based on antiarrhythmic: Group1(amiodarone), Group2(propafenone), Group3(metoprolol). Type of arrhythmia, cardioversion rates, demographic, haemodynamic, laboratory parameters were recorded in the first 24h. The outcome data were compared between the groups. RESULTS: 234 patients (99.1% ventilated) were included, the prevailing arrhythmia was acute onset atrial fibrillation (AF,69.7%). Except for the dosage of noradrenaline (0.35(0.14-0.78) in Group1(n=142)vs 0.25(0.10-0.50),p<0.01 in Group2(n=78)vs 0.14(0.07-0.25)µg/kg·min,p<0.05 in Group3(n=14)) the ejection fraction of left ventricle, rates of renal replacement therapy, arterial lactate and procalcitonin levels were not different between the groups. The cardioversion rate in Group1(74%) was lower than in Group2(89%) and Group3(92%). ICU and 28-day mortalities of Group1 were not significantly higher than in Group2 and Group3. Multivariate analysis demonstrated higher 12-month mortality in Group1 than in Group2 (HR1.58(1.04;2.38),p=0.03). CONCLUSIONS: Propafenone demonstrated a higher cardioversion rate than amiodarone with a similar impact on the outcome. Patients remaining in acute onset arrhythmia did not demonstrate significantly higher ICU, 28-day and 12-month mortalities compared to those successfully cardioverted or to those having chronic AF.

Chronic dietary exposure to branched chain amino acids impairs glucose disposal in vegans but not in omnivores.

BACKGROUND/OBJECTIVES: Branched chain amino acids (BCAA) are among nutrients strongly linked with insulin sensitivity (IS) measures. We investigated the effects of a chronic increase of BCAA intake on IS in two groups of healthy subjects differing in their basal consumption of BCAA, that is, vegans and omnivores. SUBJECTS/METHODS: Eight vegans and eight matched omnivores (five men and three women in each group) received 15 g (women) or 20 g (men) of BCAA daily for 3 months. Anthropometry, blood analyses, glucose clamp, arginine test, subcutaneous abdominal adipose tissue (AT) and skeletal muscle (SM) biopsies (mRNA levels of selected metabolic markers, respiratory chain (RC) activity) were performed at baseline, after the intervention and after a 6 month wash-out period. RESULTS: Compared with omnivores, vegans had higher IS at baseline (GIR, glucose infusion rate: 9.6±2.4 vs 7.1±2.4 mg/kg/min, 95% CI for difference: 0.55 to 5.82) that declined after the intervention and returned to baseline values after the wash-out period (changes in GIR with 95% CI, 3-0 months: -1.64 [-2.5; -0.75] and 9-3 months: 1.65 [0.75; 2.54] mg/kg/min). No such change was observed in omnivores. In omnivores the intervention led to an increased expression of lipogenic genes (DGAT2, FASN, PPARγ, SCD1) in AT. SM RC activity increased in both groups. CONCLUSIONS: Negative impact of increased BCAA intake on IS was only detected in vegans, that is, subjects with low basal amino acids/BCAA intake, which appear to be unable to induce sufficient compensatory changes within AT and SM on a BCAA challenge.

Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease.

INTRODUCTION: The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases. MATERIALS AND METHODS: The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event. RESULTS: Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3). CONCLUSIONS: The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.

THA and TKA in patients with cardiovascular disease: What makes the risk of perioperative bleeding?

Backround: The purpose of the study was to ascertain the incidence of bleeding and ischaemic complications in patients with cardiac disease after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: In total, 477 patients (289 women, 188 men) with known history of cardiac disease or thromboembolic disease treated with surgery in 2010-2013, were enrolled in the study. Perioperative prevention of thromboembolic disease using low-molecular-weight heparins was applied in all the patients. The data that could have an impact on the development of monitored perioperative complications, were observed. RESULTS: Complications occurred in 55 (11.6 %) patients: bleeding complications in 32, ischaemic in 19, and both in four patients. Complications were found in 13 (12.0 %) patients after THA and in 6 (9.5 %) patients after TKA. Bleeding complications were observed in 17 patients after THA and TKA, ischaemic in one, and both simultaneously in one patient.Bleeding complications occurred insignificantly more frequently after THA and TKA (p = 0.094); however, this difference was statistically significant after adjustment for risk factors (p = 0.003). On the contrary, ischaemic complications were significantly more frequent after other skeletal surgeries (p = 0.014). Nevertheless, this difference was not statistically significant after the adjustment (p = 0.880). The comparison of the risk of complications in patients after THA with that in patients after TKA showed no significant difference (p = 0.580). CONCLUSION: The study showed a significantly higher incidence of bleeding complications in patients after THA and TKA compared to other surgeries of the musculoskeletal system in patients with a history of cardiac disease. Bleeding complications cannot be detected in advance (Tab. 1, Ref. 16).

Paraspinal muscle volume in patients with Scheuermann's Kyphosis.

To measure the cross-sectional area (CSA) of para-spinal muscles in Scheuermann's kyphosis patients. Preoperative MRI images of 16 Scheuermann's kyphosis patients were analysed and compared to 16 patients with normal MRI images (control group). The CSAs were measured at L3-4 and L4-5. Both groups showed similar demographics and patient characteristics. The multifidus muscles CSA were found to be significantly smaller at L3/4 level in Scheuermann's kyphosis patients (p = 0.022 on the left and p = 0.016 on the right side compared to control group). There was no significant change in multifidus CSA found at L4/5. The mean CSA of the extensor spinae muscles group were significantly smaller at all levels in Scheuermann's kyphosis patients : p = 0.001 bilaterally at L3/4 and p = 0.015 right side and p = 0.009 left side at L4/5 level. This study shows that patients with Scheuermann's kyphosis deformity have significantly smaller CSA of lumbar multifidus and extensor spinae muscles.

[Fracture Type and Injury-to-Surgery Interval as Risk Factors for Avascular Necrosis of the Femoral Head after Internal Fixation of Intracapsular Femoral Neck Fracture]. / Typ zlomeniny a interval úraz-operace jako rizikové faktory pro vznik avaskulární nekrózy hlavice femuru po osteosyntéze intrakapsulárních zlomenin krcku.

PURPOSE OF THE STUDY: The aim of the study was to investigate the occurrence of avascular necrosis (AVN) of the femoral head following the osteosynthesis of intracapsular fracture of the femoral neck in relation to the time interval between injury and surgery and the type of fracture. MATERIAL AND METHODS: The data of patients with intracapsular fractures of the femoral neck surgically treated in the period from 2001 to 2011 were reviewed. Of 1555 patients treated for this fracture, 125 (7%) underwent osteosynthesis. The evaluated group included 115 patients who came for examination at one-year follow-up. There were 59 (52%) women and 56 (48%) men. Dynamic hip screw (DHS) osteosynthesis with an anti-rotation screw was performed in 103 patients and lag-screw osteosynthesis involving three parallel cannulated cancellous screws was employed in 12 patients. The patients were allocated to groups according to the injury-to-surgery interval and to sub-groups on the basis of the Garden classification of femoral fracture stage. RESULTS: In the group of 58 patients treated within 6 h of injury, AVN developed in 10 (17%). When the type of fracture was considered, 4% of the non-displaced fractures and 30% of the displaced fractures developed AVN. The patients with Garden stage I and II (non-displaced) fractures treated within 6 h of injury had a significantly lower risk of AVN development than those with Garden stage III or IV (displaced) fractures. The group treated between 6 and 24 post-injury hours comprised 21 patients, of whom four (19%) had AVN. In non-displaced and displaced fracture sub-groups, 25% of the patients in the former and 16% in the latter had AVN. The stage of displacement had no effect on AVN development. The two groups together (patients treated by 24 h) had a significantly lower AVN incidence than the patients treated after 24 h (p = 0.0025). In this group of 36 patients, 16 had AVN (44%) and the fracture stage made no significant difference (p = 0.6985; nondisplacement sub-group, 41%; displacement sub-group, 55%). CONCLUSIONS: The study showed a significantly lower AVN occurrence in the patients surgically treated within 24 h of injury. In the patients treated within 6 h of injury, AVN incidence was significantly lower in the patients with non-displaced fractures, as compared with those who had displaced fractures. This was not true for the two patient groups treated later (6-24 and later than 24 h) in which the differences between AVN development after non-displaced fractures and that after displaced fractures were similar.

Biochemical Testing After Pheochromocytoma Removal: How Early?

Pheochromocytomas are catecholamine-producing tumors with typical clinical presentation. Tumor resection is considered as an appropriate treatment strategy. Due to its unpredictable clinical behavior, biochemical testing is mandatory to confirm the success of tumor removal after surgery. The aim of the study was to investigate the feasibility of a shorter interval of postoperative testing (earlier than the recommended 2-4 weeks according to recently published Guidelines). We investigated 81 patients with pheochromocytoma before and after surgery. Postoperative examination was performed of stable subjects after their transport from the surgical to the internal ward (7.1±2.2 days after surgery). Plasma metanephrines were used for the diagnosis of pheochromocytoma and confirmation of successful tumor removal. All subjects with pheochromocytoma had markedly elevated plasma metanephrines before surgery. No correlation between postoperative interval (the shortest being 3 days) and plasma metanephrine levels was found. Postoperative plasma metanephrine levels did not differ significantly from those taken at the one-year follow-up. In conclusion, we have shown that early postoperative diagnostic workup of subjects with pheochromocytoma is possible and may thus simplify early postoperative management of this clinical condition.

Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry.

BACKGROUND: Interruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD). METHODS: All 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered. RESULTS: In-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications. CONCLUSIONS: Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.

[Scapular fracture related to polytrauma severity in patients with serious brachial plexus palsy]. / Souvislost zlomeniny lopatky se závazností polytraumatu u pacientu s tezkou lézí plexus brachialis.

PURPOSE OF THE STUDY: Brachial plexus palsy is often accompanied by other injuries. Scapular fracture is thought to be a marker of polytrauma severity. The aim of this study was to evaluate associated injuries in patients with serious brachial plexus involvement and to determine whether there is a relationship between scapular fracture and severity of polytrauma in such patients. MATERIAL AND METHODS: We retrospectively evaluated 84 surgical patients who underwent brachial plexus reconstruction at our department between 2008 and 2011. In all of them, data on scapular fracture and major associated injuries were recorded. RESULTS: Of the 84 patients, 22 (26.2%) had a scapular fracture. Of 61 patients with upper plexus palsy only 10 (16.4%) suffered a scapular fracture while of 23 patients with more severe plexus lesions 12 (52.2%, p<0.001) had fractured scapula. The ISS score in the patients with fractured scapula was significantly higher (51.8, SD=11, range=18-75, p<0.001). The patients with scapular fractures also had a significantly higher number of rib, clavicle, upper and lower limb fractures, and injuries to the thoracic organs and the head. CONCLUSIONS: Both scapular fracture and serious brachial plexus injury are usually associated with other severe injuries. They occur due to high-energy trauma. Generally, patients who sustain scapular fractures and upper limb impairment in motorcycle and car crashes are at high risk of other associated injuries and more severe polytrauma.

[Mortality risk in polytrauma patients with pelvic injury]. / Riziko umrtí u polytraumatizovaných pacientu s poranením pánve.

The aim of the study is to present results showing whether a pelvic injury in polytrauma patients means a high risk of mortality. The retrospective study (January 2001 - December 2006) included 453 polytrauma patients (130 women, 323 men) with ISS exceeding 16 points, hospitalized at the authors' department (Traumacentre Level I). The age of patients ranged between 13-93 years, the mean age of the whole group was 41 years (43 years in women, 40 years in men). The highest percentage of the deceased was recorded in the subgroup with abdominal injury (35%) and in the subgroup with pelvic injury (31%), the lowest in the subgroup without abdominal injury (20%). A significant difference was recorded between the numbers of deceased patients with and without abdominal trauma (p < 0.001), and between the numbers of patients with and without pelvic injury (p = 0.046). The results of the study have demonstrated a significantly higher rate of mortality in polytrauma patients with ISS > 16 points, with a simultaneous pelvic injury as compared to the patients without pelvic injury.

[Polytraumas in injured patients over 65 years of age]. / Polytrauma u zranených starsích 65 let.

INTRODUCTION: Geriatric trauma is most commonly defined as a trauma in patients of 65 years of age and over. These patients represent a specific problem due to their vulnerability, limited physiological response to the traumatic stress and high frequency of associated disorders, complicating the treatment. The aim of this report is to assess polytrauma patients of 65 years of age and older, compared to a group of younger patients. PATIENTS, METHODOLOGY AND RESULTS: 198 polytrauma patients, hospitalized from 2005 to 2006 were included in the retrospective study. Out of the total, 27 subjects (13.6%) were 65+ years old. Upon their admission, the difference in APACHE II between the groups was highly statistically significant (19-27.2, p = 0.0001). The ISS (the mean value) score was higher in the elderly patients (29-38). Traffic injuries, including pedestrian-vehicle collisions (61-73%), were the commonest mechanism of injuries in the both groups. There was a significant difference in the rates of craniocerebral injuries (80-96%, p = 0.041). During the early posttraumatic period, 99 (57%) urgent surgical procedures were performed in younger patients, compared to 11 (79%) procedures in the elderly. The difference in death rates was statistically significant (25-44%, p = 0.031). CONCLUSION: Polytraumas in the elderly (65 years of age and over) injured is characterized by higher severity scores and higher rates of craniocerebral injuries. Traffic injury was the commonest mechanism of injury. The death rate was higher in the elderly patients.

Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients.

OBJECTIVE: The aim was to develop a practical method for estimation of the volume of pleural effusion using ultrasonography in mechanically ventilated patients. DESIGN: Prospective observational study. SETTING: 20-bed general intensive care unit in the university hospital. PATIENTS AND PARTICIPANTS: 81 patients were included after initial suspicion of pleural fluid on chest supine X-ray and pre-puncture ultrasound confirming effusion. Patients with thoracic deformities, post-lung surgery, with diaphragm pathology, haemothorax, empyema and with incomplete aspiration of pleural fluid on post-puncture ultrasound were excluded. INTERVENTIONS: Patients were supine with mild trunk elevation at 15 degrees . Probe was moved upwards in posterior axillary line, and transverse section perpendicular to the body axis was obtained with pleural separation visible at lung base. The maximal distance between parietal and visceral pleura (Sep) in end-expiration was recorded. Thoracentesis was performed at previous probe position and volume of pleural fluid (V) recorded. MEASUREMENTS AND RESULTS: 92 effusions were evaluated and drained; 11 (12%) were excluded for incomplete aspiration. Success rate of obtaining fluid under ultrasound guidance was 100%; the incidence of pneumothorax or bleeding was zero. Mean Sep was 35+/-13 mm. Mean V was 658+/-320 ml. Significant positive correlation between both Sep and V was found: r=0.72; r(2)=0.52; p<0.001. The amount of pleural fluid volume can be estimated with the simplified formula: V (ml)=20 x Sep (mm). Mean prediction error of V using Sep was 158.4+/-160.6 ml. CONCLUSIONS: Easy quantification of pleural fluid may help to decide about performing thoracentesis in high-risk patients, although thoracentesis under ultrasound guidance appears to be a safe procedure.

Normocapnic high-frequency oscillatory ventilation affects differently extrapulmonary and pulmonary forms of acute respiratory distress syndrome in adults.

The recently reported differences between pulmonary and extrapulmonary acute respiratory distress syndromes (ARDS(p), ARDS(exp)) are the main reasons of scientific discussion on potential differences in the effects of current ventilatory strategies. The aim of this study is to assess whether the presence of ARDS(p) or ARDS(exp) can differently affect the beneficial effects of high-frequency oscillatory ventilation (HFOV) upon physiological and clinical parameters. Thirty adults fulfilling the ARDS criteria were indicated for HFOV in case of failure of conventional ventilation strategy. According to the ARDS type, each patient was included either in the group of patients with ARDS(p) or ARDS(exp). Six hours after normocapnic HFOV introduction, there was no significant increase in PaO2/F(I)O2 in ARDS(p) group (from 129+/-47 to 133+/-50 Torr), but a significant improvement was found in ARDS(exp) (from 114+/-54 to 200+/-65 Torr, p<0.01). Despite the insignificant difference in the latest mean airway pressure (MAP) on conventional mechanical ventilation (CMV) between both groups, initial optimal continuous distension pressure (CDP) for the best PaO2/F(I)O2 during HFOV was 2.0+/-0.6 kPa in ARDS(p) and 2.8+/-0.6 kPa in ARDS(exp) (p<0.01). HFOV recruits and thus it is more effective in ARDS(exp). ARDS(exp) patients require higher CDP levels than ARDS(p) patients. The testing period for positive effect of HFOV is recommended not to be longer than 24 hours.

Prostacyclin versus citrate in continuous haemodiafiltration: an observational study in patients with high risk of bleeding.

BACKGROUND: The efficacy and safety of prostacyclin (PGI2) and citrate (ACD) anticoagulation were observed and compared during continuous haemodiafiltration. METHODS: Mechanically ventilated patients received either the PGI2 analogue epoprostenol (group A, n = 17) in escalating doses of 4.5-10.0 ng.kg(-1).min(-1) in combination with heparin (6 IU.kg(-1).h(-1)) or 2.2% ACD (group B, n = 15). Blood flow was set to match the circuit-filling volume per unit time equal to the intravascular half-life of PGI2. RESULTS: Median filter lifetimes were 26 h (interquartile range 16-37) in group A (39 filters) and 36.5 h (interquartile range 23-50) in group B (56 filters; p < 0.01). In group A, 4 patients (23.5%, p < 0.05) had the dose reduced due to hypotension. The final mean dose of PGI2 was 8.7 +/- 2.4 ng.kg(-1).min(-1). Four patients in group A (23.5%, p < 0.05) were switched to ACD due to a decrease in platelet count. No bleeding episodes, decrease in platelet count or adverse haemodynamic effects were encountered in group B. The cost of epoprostenol plus low dose heparin (EUR 204.73 +/- 53.04) was significantly higher than the cost of ACD-based anticoagulation (EUR 93.92 +/- 45.2, p < 0.05). CONCLUSION: ACD offers longer filter survival, has no impact on platelet count and is less expensive. Increasing the dose of PGI2 up to the average of 8.7 ng.kg(-1).min(-1) did not increase the haemodynamic side effects.

Can bioimpedance determine the volume of distribution of antibiotics in sepsis?

The relationship between the volume of distribution, assessed according to the two-compartmental pharmacokinetic model, and extracellular water estimated by bioimpedance was studied in mechanically ventilated patients with sepsis and capillary leak. A prospective observational study was performed in a twenty-bed general intensive care unit in the university hospital. Patients received either vancomycin (n = 16) or netilmicin (n = 12) for more than 48 hours. Those with ascites, pleural effusion, on renal replacement therapy or with haemodynamic instability were excluded. Serum concentrations of drugs were taken for pharmacokinetic analysis before, 1 hour and 4 hours after the 30 minute infusion. Bioimpedance measurement was performed at the time of the third sampling. The protocol was repeated after 24 hours. Fluid balance during the 24 hour interval was recorded. Extracellular water was increased and represented 45.6 to 46.6% of total body water Fluid balance correlated with the change of extracellular water (r = 0.82, P < 0.0001) and total body water (r = 0.74, P < 0.0001). Volumes of distribution of vancomycin (0.677 +/- 0.339 l/kg) and netilmicin (0.505 +/- 0.172 l/kg) were increased compared to normal values. A correlation was demonstrated between volume of distribution (Vd(area)) of vancomycin and extra cellular water/total body ratio (r = 0.70, P < 0.0001). The central compartment distribution volume (V1) of netilmicin correlated with extracellular water/total body water ratio (r = 0.60, P < 0.003). Serum concentrations above the recommended therapeutic range were detected in 81.2% of patients on vancomycin and in 50% of patients on netilmicin. Increased volumes of distribution can be estimated by the bioimpedance measurements but are not associated with requirements for higher dosage of the glycopeptide or aminoglycoside antibiotics.

The effect of subarachnoid sodium nitroprusside on the prevention of vasospasm in subarachnoid haemorrhage.

OBJECTIVE: The aim of this study was to evaluate the effect of preventive and therapeutic use of subarachnoid sodium nitroprusside (SNP) administration in patients with non-traumatic subarachnoid haemorrhage (SAH). METHODS: All consecutive adult patients admitted in the period 2000-2003 with SAH, Hunt-Hess grade I-IV, indicated for neurosurgical intervention, were enrolled in the study. In the postoperative period they were treated with mechanical ventilation and triple H protocol with nimodipine. Subarachnoid preventive SNP was administred in initial dose of 1 mg by catheter inserted into basal cisterns during the neurosurgical procedure. The timing of following dosage was directed by the changes of respiratory parameters of brain tissue in the region of interest by multiparameter sensor (Codman Neurotrend) and findings of blood flow velocity on the level of circle of Willis were measured by transcranial doppler ultrasonography (TCD). RESULTS: 17 patients were enrolled to study. All patients survived. No brain infarction developed. The increase blood flow velocity was found in three patients. CONCLUSION: Preventive subarachnoid use of SNP in combination with multimodal monitoring might be a possible preventive strategy. Its efficacy has to be proved on a greater group of patients in the future. The therapeutical use of SNP requires an increase in application rate.