Interleukin 33, soluble suppression of tumorigenicity 2, interleukin 27, and galectin 3 as predictors for outcome in patients admitted to intensive care units.

Intensive care units (ICUs) are expert hospital areas that provide treatment and 24 h care for people who are very sick. Sepsis represents a serious, severe condition and it can lead to septic shock and multiple organ dysfunction syndromes and is one of the most common reasons for patients' hospitalization in ICUs. We wanted to explore the prognostic values of interleukin (IL) 33, soluble suppression of tumorigenicity 2 (sST2), IL 27, and galectin 3 in critically-ill patients. We assumed that these parameters in combination or alone could predict mortality in ICU patients. This research represents a clinical non-randomized prospective study, performed at the Medical Military Academy, a tertiary care hospital in Belgrade, Serbia. The patients were divided in four groups: patients with sepsis (peritonitis, pancreatitis, trauma) and patients without sepsis (trauma). Total number of patients enrolled in the study was 151 and average years of patients were 56.48. The values greater than the cut-off were the predictors of mortality. The IL-33, IL-27 as well as galectin-3 can successfully predict the outcome of critically-ill patients in ICUs. The sST2, cannot predict death in critically-ill patients as a single prognostic factor. However, the combination of at least two biomarkers: IL-33, sST2, IL-27, and galectin-3, gives very significant results in predicting the outcome in patients admitted to ICUs.

Correlation of Redox Status with Procalcitonin and C-reactive Protein in Septic Patients.

Based on the role of oxidative stress in the pathophysiological mechanisms of sepsis and the importance of PCT as a clinically applicable biomarker for early detection of inflammatory response initiation, we aimed this study at examining the correlation between PCT levels and oxidative stress parameters (prooxidants and antioxidants) in patients with sepsis. This study was designed as a case-series prospective clinical study which involved 103 critically ill patients and 17 healthy participants with diagnosis of sepsis/septic shock (over 18 years of age, both gender) admitted to the Intensive Care Unit (ICU) of Valjevo General Hospital in Serbia. All subjects were divided into patients who were operated on/underwent surgery before sampling and have sepsis (n = 24), patients who were operated on/underwent surgery before sampling and have septic shock (n = 25), patients who were not operated on/did not undergo surgery before sampling and have sepsis (n = 26), patients who were not operated on/did not undergo surgery before sampling and have septic shock (n = 28), and participants who are healthy (n = 17). PCT has confirmed a positive correlation with prooxidants and type of critical illness, and performing surgical intervention diminished oxidative stress in patients with septic shock. Prognosis in critically ill patients was strongly associated with PCT levels but not with nonspecifically C-reactive protein.

Neutrophil-to-Lymphocyte Ratio, Monocyte-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Mean Platelet Volume-to-Platelet Count Ratio as Biomarkers in Critically Ill and Injured Patients: Which Ratio to Choose to Predict Outcome and Nature of Bacteremia?

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume-to-platelet count (MPV/PC) ratio are readily available parameters that might have discriminative power regarding outcome. The aim of our study was to assess prognostic value of these biomarkers regarding outcome in critically ill patients with secondary sepsis and/or trauma. METHODS: A total of 392 critically ill and injured patients, admitted to surgical ICU, were enrolled in a prospective observational study. Leukocyte and platelet counts were recorded upon fulfilling Sepsis-3 criteria and for traumatized Injury Severity Score > 25 points. Patients were divided into four subgroups: peritonitis, pancreatitis, trauma with sepsis, and trauma without sepsis. RESULTS: NLR and MPV/PC levels were significantly higher in nonsurvivors (AUC/ROC of 0.681 and 0.592, resp., in the peritonitis subgroup; 0.717 and 0.753, resp., in the pancreatitis subgroup); MLR and PLR did not differ significantly. There was no significant difference of investigated biomarkers between survivors and nonsurvivors in trauma patients with and without sepsis except for PLR in the trauma without sepsis subgroup (significantly higher in nonsurvivors, AUC/ROC of 0.719). Independent predictor of lethal outcome was NLR in the whole cohort and in the peritonitis subgroup as well as MPV in the pancreatitis subgroup. Also, there were statistically significant differences in MPV/PC, MLR, and PLR values regarding nature of bacteremia. In general, the lowest levels had been found in patients with Gram-positive blood cultures. CONCLUSIONS: NLR and MPV were very good independent predictors of lethal outcome. For the first time, we demonstrate that nature of bacteremia influences MPV/PC, MLR, and PLR. In heterogeneous cohort subgroup, analysis is essential.

Efficacy of external warming in attenuation of hypothermia in surgical patients.

BACKGROUND/AIM: Hypothermia in surgical patients can be the consequence of long duration of surgical intervention, general anaesthesia and low temperature in operating room. Postoperative hypothermia contributes to a number of postoperative complications such as arrhythmia, myocardial ischemia, hypertension, bleeding, wound infection, coagulopathy, and prolonged effect of muscle relaxants. External heating procedures are used to prevent this condition. The aim of this study was to evaluate the efficiency of external warming system in alleviation of cold stress and hypothermia in patients who underwent major surgical procedures. METHODS: The study was conducted in the Military Medical Academy in Belgrade. A total of 30 patients of both genders underwent abdominal surgical procedures, randomly divided into two equal groups: the one was externally warmed using warm air mattress (W), while in the control group (C) surgical procedure was performed in regular conditions, without additional warming. Oesophageal temperature (Te) was used as indicator of changes in core temperature, during surgery and awakening postoperative period, and temperature of control sites on the right hand (Th) and the right foot (Tf) reflected the changes in skin temperatures during surgery. Te and skin temperatures were monitored during the intraoperative period, with continuous measurement of Te during the following 90 minutes of the postoperative period. Heart rates and blood pressures were monitored continuously during the intraoperative and awakening period. RESULTS: In the W group, the average Te, Tf and Th did not change significantly during the intraoperative as well as the postoperative period. In the controls, the average Te significantly decreased during the intraoperative period (from 35.61 ± 0.35 °C at 0 minute to 33.86 ± 0.51°C at 120th minute). Compared to the W group, Te in the C group was significantly lower in all the observed periods. Average values of Tf and Th significantly decreased in the C group (from 30.83 ± 1.85 at 20th minute to 29.0 ± 1.39°C at 120th minute, and from 32.75 ± 0.96 to 31.05 ± 1.09°C, respectively). CONCLUSION: The obtained results confirm that the external warming using warm air mattress was able to attenuate hypothermia, i.e. substantial decrease in core temperature, compared with the similar exposure to cold stress in the control group.

Cytokine profile in severe Gram-positive and Gram-negative abdominal sepsis.

Sepsis is a principal cause of death in critical care units worldwide and consumes considerable healthcare resources. The aim of our study was to determine whether the early cytokine profile can discriminate between Gram-positive and Gram-negative bacteraemia (GPB and GNB, respectively) and to assess the prognostic value regarding outcome in critically ill patients with severe abdominal sepsis. The outcome measure was hospital mortality. Blood samples were obtained from 165 adult patients with confirmed severe abdominal sepsis. Levels of the proinflammatory mediators TNF-α, IL-8, IL-12 and IFN-γ and the anti-inflammatory mediators IL-1ra, IL-4, IL-10 and TGF-ß1 were determined and correlated with the nature of the bacteria isolated from the blood culture and outcome. The cytokine profile in our study indicated that the TNF-α levels were 2-fold, IL-8 were 3.3-fold, IFN-γ were 13-fold, IL-1ra were 1.05-fold, IL-4 were 1.4-fold and IL-10 were 1.83-fold higher in the GNB group compared with the GPB group. The TNF-α levels were 4.7-fold, IL-8 were 4.6-fold, IL-1ra were 1.5-fold and IL-10 were 3.3-fold higher in the non-survivors compared with the survivors.

Prognostic Value and Daily Trend of Interleukin-6, Neutrophil CD64 Expression, C-Reactive Protein and Lipopolysaccharide-Binding Protein in Critically Ill Patients: Reliable Predictors of Outcome or Not?

BACKGROUND: Severe sepsis and/or trauma complicated by multiple organ dysfunction syndrome are the leading causes of death in critically ill patients. The aim of this prospective single-centre study was to assess the prognostic value and daily trend of interleukin-6 (IL-6), neutrophil CD64 expression, C-reactive protein (CRP) and lipopolysaccharide-binding protein (LBP) regarding outcome in critically ill patients with severe trauma and/or severe sepsis. Outcome measure was hospital mortality. METHODS: One hundred and two critically ill patients admitted to the intensive care unit of a tertiary university hospital were enrolled in this prospective study. Blood samples were collected on admission (day 1), days 2 and 3. RESULTS: CD64 index was 1.6-fold higher on day 1 and 1.78-fold higher on day 2 in non-survivors (p<0.05). The area under the curve (AUC) for the CD64 index on day 1 for outcome was 0.727. At a cut-off level of 2.80 sensitivity was 75% and specificity was 65%. Patients with CD64 index level on day 1 higher than 2.80 had 2.4-fold higher probability of dying. Odds ratio is 2.40; 95% CI 0.60-9.67. CONCLUSIONS: CD64 index on day 1 is a fairly good predictor of outcome. AUCs for IL-6, CRP and LBP were < 0.55, suggesting these biomarkers failed to predict outcome.

Addition of glucagon to adrenaline improves hemodynamics in a porcine model of prolonged ventricular fibrillation.

OBJECTIVE: Cardiac arrest is a daunting medical emergency. The aim of the present study was to assess whether the combination of adrenaline and glucagon would improve initial resuscitation success, 48-hour survival, and neurologic outcome compared with adrenaline alone in a porcine model of ventricular fibrillation. METHODS: Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 minutes. The animals were randomized to receive adrenaline alone (n = 10, group C) and adrenaline plus glucagon (n = 10, group G). All animals were resuscitated according to the 2010 European Resuscitation Council guidelines. Hemodynamic variables were measured before arrest, during arrest and resuscitation, and during the first 60 minutes after return of spontaneous circulation. Survival and a neurologic alertness score were measured at 48 hours after return of spontaneous circulation. RESULTS: Return of spontaneous circulation was achieved in 8 animals (80%) from group C and 10 animals (100%) from group G (P = .198). A significant gradual increase in coronary perfusion pressure and diastolic aortic pressure over time, which started 1 minute after the onset of cardiopulmonary resuscitation, was observed. Three animals (30%) from group C and 9 animals (90%) from group G survived after 48 hours (P = .006), whereas neurologic examination was significantly better in the animals of group G (P < .001). CONCLUSIONS: In this porcine model of prolonged ventricular fibrillation, the addition of glucagon to adrenaline improves hemodynamics during resuscitation and early postresuscitation period and may increase survival.

Immunoinflammatory response in critically ill patients: severe sepsis and/or trauma.

Immunoinflammatory response in critically ill patients is very complex. This review explores some of the new elements of immunoinflammatory response in severe sepsis, tumor necrosis factor-alpha in severe acute pancreatitis as a clinical example of immune response in sepsis, immune response in severe trauma with or without secondary sepsis, and genetic aspects of host immuno-inflammatory response to various insults in critically ill patients.

Immune response in severe infection: could life-saving drugs be potentially harmful?

Critically ill patients suffer a high rate of nosocomial infection with secondary sepsis being a common cause of death. Usage of antibiotics and catecholamines is often necessary, but it can compromise complex immune response to infection. This review explores influence of these life-saving drugs on host immune response to severe infection.

Effect of pretreatment with omega-3 polyunsaturated fatty acids (PUfas) on hematological parameters and platelets aggregation in patients during elective coronary artery bypass grafting.

BACKGROUND/AIM: [corrected] Using omega-3 polyunsaturated fatty acids (PUFAs) in coronary artery bypass graft surgery (CABG) could provide protection against ischemic-reperfusion damage, prevention of postoperative arrhyth mia and attenuation of inflammatory response. However, omega-3 PUFAs inhibit cyclooxygenase (and thus decrease the synthesis of thromboxane A2 from arachidonic acid in platelets), which leads to decreased platelet aggregation. In cardiac surgery it is necessary to achieve a balance between inhibition and full platelets function. It is as well as im portant to closely follow hematological parameters, im paired by CABG itself. Therefore, the aim of the study was to establish the effects of pretreatment with omega-PUFAs on hematological parameters and plateletes aggre gation in patients with elective CABG. METHODS: This prospective, randomized, placebo-controlled, single-center trial was performed on parallel groups. The patients (n = 40) undergoing elective CABG were randomized receivin preoperative intravenous omega-3 PUFAs (Omegaven 10%) infusion (the PUFAs group) or the same volume of 0.9% saline solution infusion (the control group). Infusion was given a day before surgery and repeated four hours before starting extracorporeal circulation (CPB) via the pe ripheral vein at single doses of 100 mL (25 mL/h). Platelet function analysis was performed using multiple electrode aggregometry (MEA, multiplate-analyzer) before starting CPB and 2 h postoperatively for the patients of both groups. Results. There were no clinically relevant differ ences in baseline characteristics between the groups. He matological parameters were not significantly different between the groups pre-, intra- and postoperatively. Dur ing the first 24 h after surgery, the loss of blood was simi lar in the PUFAs and the control group (680 +/- 274 mL and 608 +/- 210 mL, respectively; p = 0.356). Postopera tively, platelet aggregation was not significantly different between the PUFAs and the control group in adenosine diphosphate (ADP) test (39 +/- 11 and 42 +/- 15, respec tively; p = 0.701), arachidonic acid (ASPI) test (64 +/- 24 and 70 +/- 27, respectively; p = 0.525) and trombin receptor-activating peptide (TRAP) test (68 +/- 25 and 75 + 26, respectively; p = 0.396), while their aggregation in collagen (COL) test was statistically significantly lower in the PUFAs related to the control group (32 +/- 15 and 47 +/- 20, re spectively; p = 0.009). Conclusion. Acute pretreatment with omega-3 PUFAs insignificantly affected the activity of platelets and did not influence postoperative blood loss.

Cancer of ectopic parathyroid gland presentation of the disease with a case report.

Tc-99m-methoxyisobutylisonitril (MIBI) scintigraphy is localizing diagnostic methods that is used for detection of sicken parathyroid gland (PT). The use of this method for PT diseases diagnosis makes surgical treatment of a patient more successful. This is a report about the patient who was surgically treated for primary hyperparathyroidism caused by hyperplasia of parathyroid glands and cancer of ectopic parathyroid gland. He was operated in two acts. The first surgical intervention was performed without preoperative diagnostics of Tc-99m-MIBI scintigraphy, while the second surgical intervention was preceded by Tc-99m-MIBI scintigraphy which clearly showed the existence of tumor in the back mediastinum (ectopic parathyroid gland). Pathophysiological analysis of the extirpated parathyroid gland showed the case of ectopic parathyroid gland cancer. The use of Tc-99m-MIBI scintigraphy as a localizing method before the first surgical intervention could have saved the patient from the second one and from risks it could have caused, as well.

[Deep sedation with midazolam and propofol in children undergoing ambulatory magnetic resonance imaging of the brain].

UNLABELLED: BACKROUND/AIM: Sedation is necessary in children undergoing magnetic resonance imaging (MRI) to ensure motionless. The success of sedation is typically measured by two factors: safety (lack of adverse events) and effectiveness of the procedure (successful completion of the diagnostic examination). Propofol is frequently used to induce deep sedation in children. However, increased doses of propofol may lead to oversedation and respiratory depression. The aim of the study was to investigate sedation in children using propofol with midazolam in regard to efficacy, adverse events and time to return to presedation functional status. METHODS: We investigated 24 children prospectively. Sedation was introduced with a single bolus of intravenous (iv) midazolam 0.1 mg/kg followed by repeated small iv boluses of propofol until sufficient depth of sedation was obtained. The outcome of sedation was measured by the induction time, sedation time, need for additional sedation, respiratory events, cardiovascular events and sedation failure. RESULTS: Median age of children was 4.72 +/- 3.06 (1.1-12.3) years and their body weight was 21.3 +/- 11.9 (11-60) kg. Average propofol bolus dose for induction was 1.76 +/- 0.9 (0.5-4) mg/kg. The induction time was 8.88 +/- 2.92 (5-15) min, and sedation time 28.39 +/- 8.42 (20-50) min. Additional sedation was necessary in 3 (12.5%) patients. Unsucesfull sedation or significant adverse events were not observed. CONCLUSION: The presented sedation technique for children undergoing ambulatory MRI of the brain is safe and adequate. This sedation regiment provides short induction time, fast recovery, stable cardiorespiratory conditions and rarely demans additional sedation.

Predictive value of serum bicarbonate, arterial base deficit/excess and SAPS III score in critically ill patients.

Arterial base deficit/excess (BD/E) is commonly used marker of metabolic acidosis in critically ill patients, but requires an arterial puncture and blood gas analysis. We hypothesized that serum bicarbonate (HCO3), which can be routinely obtained, strongly correlates with arterial BD/E and provides equivalent predictive information. In addition, we evaluated predictive value of simplified acute physiology score III (SAPS III). Total of 152 critically ill surgical patients were included in retrospective analysis. On admission to intensive care unit sets of simultaneously obtained paired laboratory data, including an arterial blood gas and serum chemistry panel with serum HCO3 were obtained. Very strong correlation between BD/E and simultaneously measured serum HCO3 levels was found (r = 0.857, R(2) = 0.732, p < 0.01). The serum HCO3 level reliably identified a significant metabolic acidosis (AUC = 0.761, p < 0.05). BD and SAPS III were good predictors of mortality (AUCs 0.70 and 0.74, respectively). Serum HCO3 may be used as substitute to detect severe metabolic acidosis. BD and SAPS III score were good predictors of mortality.

[New therapy strategies for treatment of severe sepsis and septic shock in intensive care unit of clinical centre in Kragujevac].

INTRODUCTION: Despite numerous advances in medicine, the mortality rate of severe sepsis and septic shock remains high, 30-50%. New therapy strategies include: early goal-directed therapy, fluid replacement, early and appropriate antimicrobials, source of infection control, use of corticosteroids, vasopressors and inotropic therapy, use of recombinant activated protein C, tight glucose control, low-tidal-volume mechanical ventilation. They have been shown to improve the outcomes. The adequacy and speed of treatment influence the outcome, too. OBJECTIVE: The objective was to evaluate if new therapy strategies had been integrated in our routine practice. METHOD: Patients with severe sepsis or septic shock, who were treated in the Intensive Care Unit (ICU) over a ten-month period, were analysed retrospectively. The descriptive epidemiological method was applied. Central venous catheterization, central venous pressure, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, corticosteroids, blood administration, deep vein thrombosis prophylaxis, stress ulcer prophylaxis, glucose control, were evaluated. RESULTS: 27 patients were analysed. Patient characteristics were: age, 49.9 years (18-77) with 30-day in-hospital mortality rate of 48.1%. All patients received broad-spectrum antibiotics. Blood cultures were obtained in 85.2% patients. Adequate antimicrobial treatment was applied to 59.3% and 74.1% patients had central venous pressure monitoring. Average central venous pressure was 8.47 +/- 5.6 mm Hg (-2-20). Aggressive fluid therapy was given to 33.3% of the cases and 66.7% of the patients with septic shock received vasoactive drugs while 29.6% received corticosteroids. Red blood cell transfusions were applied in 59.3% of patients. All patients received stress ulcer prophylaxis, and 37% of them deep vein thrombosis prophylaxis. The average value of morning glucose was 9.11 +/- 5.03 mmol/l (3.7-22.0). 63% of patients were mechanically ventilated. Blood lactate was not determined. CONCLUSION: Evidence-based clinical guidelines for management of severe sepsis and septic shock have not been implemented in a widespread, systematic way in the ICU of the Clinical Centre, Kragujevac. Institutional acceptance of this protocol, and education of clinicians may improve survivability for patients with sepsis.