Ultrasound assisted thrombolysis in intermediate-risk patients with pulmonary thromboembolism.

Background: Systemic thrombolytic therapy is not recommended for patients with intermediate-risk pulmonary embolism (PE) because of major bleeding and intracranial bleeding overcomes the benefit of reperfusion.Patients and methods: A total of 342 PE patients with intermediate-risk PE from the multicenter Serbian PE registry were involved in the study. Of this group, 227 were not treated with reperfusion therapy (anticoagulation only), 91 were treated with conventional thrombolysis protocols at the discretion of their physicians and 24 patients were treated with ultrasound assisted catheter thrombolysis (USACT) with the EKOS® system. All patients treated with USACT had at least one factor which is associated with an increased risk of bleeding. Other patient characteristics were similar across the treatment groups. All-cause and PE-related mortality at 30 days and rate of major bleeding at 7 days were the main efficacy and safety outcomes of the study.Results: The 30-day all-cause mortality were 11.5% versus 17.6% versus 0.0% for no reperfusion, conventional thrombolysis protocols and USACT groups (p = 0.056), respectively. The difference between the rate of 30-day PE-related mortality was in a favour of EKOS and no reperfusion compare to conventional protocols (0.0% vs. 3.5% vs. 11.0%, p = 0.013, respectively). Major bleeding at 7 days, was presented in 1.8% versus 7.7% versus 8.0% (p = 0.021) in no reperfusion, conventional thrombolysis and USACT groups with no intracranial bleeding.Conclusion: In the patients with intermediate-risk PE and at least one bleeding factor, USACT could be an alternative treatment to anticoagulant therapy only and conventional thrombolytic protocols.

General ward and pneumonia size as predictors of noninvasive ventilation failure.

INTRODUCTION: Shortage of intensive care beds has led to more frequent use of noninvasive ventilation (NIV) outside respiratory units, and data on NIV efficacy and safety on general wards is lacking. OBJECTIVE: The aim was to identify potential predictors for NIV failure. METHODS: This was a retrospective analysis of patients treated with NIV at the Institute for Pulmonary Diseases of Vojvodina from 2009 to 2013. Demographics, blood gases, chest radiographs, setting, and outcomes were analyzed to identify predictors of NIV failure. RESULTS: A total of 138 patients (65% men, mean age 66 ± 11 years) were treated with NIV. Indications for NIV were acute exacerbation of chronic obstructive pulmonary disease (85%) and cardiogenic pulmonary edema (7%), as well as respiratory insufficiency related to obesity and central hypoventilation (5%) and neuromuscular disease (3%). Rate of NIV failure was 34.8%. In 86 patients NIV was applied in the High Dependency Unit (HDU), while 52 received NIV on the general ward. Baseline characteristics in terms of gender, arterial blood gases, and the extent of consolidation on chest radiographs were similar. Patients treated in HDU were younger (64.4 ± 1.2 vs. 69.4 ± 1.5 years, p < 0.001). NIV on the general ward compared to HDU had higher rates of NIV failure (28/52 vs. 20/86, p < 0.001). Presence of consolidation involving two or more quadrants on chest radiograph (55% vs. 29%, p < 0.001) was associated with NIV failure. When adjusted for age and the extent of consolidation on chest radiograph, NIV failure was still less likely in patients treated in HDU (OR 0.23, 95% Cl 0.10-0.50). CONCLUSION: Patients with consolidation on chest X-ray and patients treated with NIV outside of dedicated respiratory units are at a higher risk for NIV failure.

When pulmonary nodules, epistaxis and renal lesion do not add up to Wegener's granulomatosis?

Wegener's granulomatosis usually presents with clinical features of systemic vasculitis affecting lung, upper respiratory tract, kidney and even a nervous system. Yet, invasive pulmonary aspergillosis is characterised by invasion of blood vessels in the lungs, but the infection often spreads to kidneys, skin and central nervous system. We report a case of a 46-year-old male patient with no prior medical history. Clinical presentation included epistaxis, hemoptysis, hematuria and proteinuria, along with pulmonary nodular infiltrates. Differential diagnosis included invasive aspergillosis and Wegener's granulomatosis, but the diagnosis was only confirmed after autopsy. Establishing diagnosis of invasive aspergillosis remains a challenge for clinicians in acute care setting.

Characteristics and outcome of mechanically ventilated patients with 2009 H1N1 influenza in Bosnia and Herzegovina and Serbia: impact of newly established multidisciplinary intensive care units.

AIM: To describe characteristics and outcome of mechanically ventilated patients admitted to three newly established intensive care units (ICU) in Bosnia-Herzegovina and Serbia for 2009 H1N1 influenza infection. METHODS: The retrospective observational study included all mechanically ventilated adult patients of three university-affiliated hospitals between November 1, 2009 and March 1 2010 who had 2009 H1N1 influenza infection confirmed by real-time reverse transcriptase-polymerase-chain-reaction (RT-PCR) from nasopharyngeal swab specimens and respiratory secretions. RESULTS: The study included 50 patients, 31 male (62%), aged 43±13 years. Median time from hospital to ICU admission was 1 day (range 1-2). Sixteen patients (30%) presented with one or more chronic medical condition: 8 (16%) with chronic lung disease, 5 (10%) with chronic heart failure, and 3 (6%) with diabetes mellitus. Thirty-two (64%) were obese. Forty-eight patients (96%) experienced acute respiratory distress syndrome (ARDS), 28 (56%) septic shock, and 27 (54%) multiorgan failure. Forty-five patients (90%) were intubated and mechanically ventilated, 5 received non-invasive mechanical ventilation, 7 (14%) high-frequency oscillatory ventilation, and 7 (14%) renal replacement therapy. The median duration of mechanical ventilation was 7 (4-14) days. Hospital mortality was 52%. CONCLUSION: Influenza 2009 H1N1 infection in three southeast European ICUs affected predominantly healthy young patients and was associated with rapid deterioration after hospital admission and severe respiratory and multiorgan failure. These emerging ICUs provided contemporary ICU services, resulting in case-fatality rate comparable to reports from well-established ICU settings.

Influenza A (H1N1)--past season's wonder flu in Vojvodina.

BACKGROUND/AIM: Influenza A (H1N1) re-emerged in the human population during 2009. The aim of this study was to describe characteristics, laboratory findings, clinical presentation and treatment outcome among patients with influenza A (H1N1) infection. METHODS: The study was performed at the Institute for Pulmonary Diseases of Vojvodina including all the patients hospitalized at the Intensive Care Unit or High Dependency Unit with confirmed, probable or suspected Influenza A (H1N1) infection between November 6th, 2009 and April 13th, 2010. RESULTS: Among 64 patients Influenza A (H1N1) infection was confirmed by rt-PCR in 50, defined as probable in 7 and as suspected in 6 patients. There was an equal number of male and female patients. Their mean age was 46 years (SD +/- 12.1). None of the patients were vaccinated against influenza. Comorbidities were present in 37 (58%) patients. There were 29 (45%) obese patients. Three patients were pregnant. The median time from symptom onset to hospital admission was 5 days (IQR 4-7). At admission, the median Modified Early Warning Score (MEWS) was 4 (IQR 3-6). The most common presenting symptoms were cough (100%) and fever (89%). The mean oxygen saturation at admission was 85.3% (SD 9.0). Auscultatory finding of wheesing in the absence of a chronic lung disease was found in 10 (15.6%) patients. Leukopenia was noted in 23 (35.9%) patients, and thrombocytopenia in 14 (21.9%) patients. Aspartate aminotransferase values were elevated in 41 (64.1%) patients, alanine aminotransferase in 32 (50%) patients, and creatine kinase in 36 (56.2%) patients. Opacities on an initial chest radiograph were predominantly patchy and the median number of the lung fields involved was 1 (IQR = 0-3). The non-survivors had statistically significantly higher MEWS at admission (p = 0.0001), lower oxygen saturation (p = 0.001), more lung fields involved on an initial chest radiograph (p = 0.006), wheezing in the absence of chronic lung disease (p = 0.02) and elevated aspartat aminotransferase (p = 0.02) and creatine kinase (p = 0.03). Acute respiratory disstress developed in 21 (32.9%) patients, and mechanical ventilation was required in 23 (36.1%) patients. Septic shock developed in 12 (18.7%) patients, and 19 (29.7%) patients had a multi-organ dysfunction. The overall hospital mortality was high--20.3% (95% CI, 11.3%-32.2%; n = 13), and especially so among the patients who required mechanical ventilation--56.5% (95% CI, 36.8%-74.40%). CONCLUSION: Timely initiation of antiviral therapy and early recognition of critically ill are important factors for reducing mortality.

[Severe form of Legionnaires' disease in an immunocompetent patient].

BACKGROUND: Legionnaires' disease (LD) is a pneumonia caused by Legionella pneumophila (LP). The disease occurs more often in immunocompromised persons and can be manifested by severe pneumonia, multiple organ failure and has a high mortality. CASE REPORT: Immunocompetent patient, male, 53-year old, with severe form of LB had fever, cough, weakness and diarrhea as the initial symptoms of the disease. Laboratory results showed increased number of leukocytes, increased values of acute phase proteins, liver enzymes and hyponatremia. Computed tomography of the chest showed the marked inflammatory lessions on both sides. Pathohistological analysis of the samples retrieved by bronchoscopy pointed to a pneumonia, and diagnosis of LD was confirmed by positive urine test for LP antigen. Later, the disease was complicated by acute adult respiratory distress syndrome (ARDS). Treatment with antibiotics (erythromycin, rifampicin, azithromycin) combined with ARDS treatment led to a clinical recovery of the patient together with complete resolution of inflammatory lesions seen on chest radiography. CONCLUSION: In severe pneumonias it is necessary to consider LD in differential diagnosis, perform tests with aim of detecting LP and apply adequate antibiotic treatment in order to accomplish positive outcome of the therapy and prevent complications.

[Ventricular fibrillation after surgical revascularization]. / Fibrilacija komora nakon hirurske revaskularizacije.

INTRODUCTION: Ventricular fibrillation (VF) presents a complete disintegrated myocardial activity associated with hemodynamic collapse and loss of consciousness requiring urgent reanimation. VF mostly occurs following myocardial infarction and endstage of ischemic heart disease in patients with ejection fraction less than 30%. MATERIAL AND METHODS: This paper analyzes occurrence of VF following coronary artery revascularization in patients undergoing surgery at the Institute of Cardiovascular Diseases in Sremska Kamenica. During the period 1994-1998, 3.186 patients underwent coronary artery revascularization procedure, whereas following it VF occurred in 20 patients (0.63%). RESULTS AND DISCUSSION: In all patients VF presented in the first postoperative week, while in 16 patients it occurred in the first 3 days following surgery. Nine patients with VF underwent left coronary artery revascularization with endarterectomy, 9 patients underwent right coronary artery revascularization with endarterectomy. One patient had a left-ventricular aneurysmectomy and 80% of patients had low ejection fraction rate--20-35%. After VF in 75% of patients urgent reoperation was performed, and only one suffered from thrombotic occlusion, that is perioerative infarction. After defibrillation patients were treated with xylocaine, amiodarone and beta-blockers. During the 30-day period following surgery, there were no lethal outcomes, whereas in the 24-month period after surgery 3 patients died. Cardiac-related death occurred in one patient, while two died due to cerebral insult. CONCLUSION: VF was not a frequent complication in our patients. Effective antiarrhythmic drugs prevent repeated VF. Beta-blockers, xy-locaine and amiodarone are drugs of choice for the treatment of malignant cardiac rhythm disturbances.