The Hemodynamic Effects of Different Pacing Modalities After Cardiopulmonary Bypass in Patients With Reduced Left Ventricular Function.

OBJECTIVES: Patients with decreased left ventricular function undergoing cardiac surgery have a greater chance of difficult weaning from cardiopulmonary bypass and a poorer clinical outcome. Directly after weaning, interventricular dyssynchrony, paradoxical septal motion, and even temporary bundle-branch block might be observed. In this study, the authors measured arterial dP/dtmax, mean arterial pressure (MAP), and cardiac index using transpulmonary thermodilution, pulse contour analysis, and femoral artery catheter and compared the effects between right ventricular (A-RV) and biventricular (A-BiV) pacing on these parameters. DESIGN: Prospective study. SETTING: Single-center study. PARTICIPANTS: The study comprised 17 patients with a normal or prolonged QRS duration and a left ventricular ejection fraction ≤35% who underwent coronary artery bypass grafting with or without valve replacement. INTERVENTIONS: Temporary pacing wires were placed on the right atrium and both ventricles. Different pacing modalities were used in a standardized order. MEASUREMENTS AND MAIN RESULTS: A-BiV pacing compared with A-RV pacing demonstrated higher arterial dP/dtmax values (846 ± 646 mmHg/s v 800 ± 587 mmHg/s, p = 0.023) and higher MAP values (77 ± 19 mmHg v 71 ± 18 mmHg, p = 0.036). CONCLUSION: In patients with preoperative decreased left ventricular function undergoing coronary artery bypass grafting, A-BiV pacing improve the arterial dP/dtmax and MAP in patients with both normal and prolonged QRS duration compared with standard A-RV pacing. In addition, arterial dP/dtmax and MAP can be used to evaluate the effect of intraoperative pacing. In contrast to previous studies using more invasive techniques, transpulmonary thermodilution is easy to apply in the perioperative clinical setting.

The Influence of End-of-Life Care on Organ Donor Potential.

Many patients with acute devastating brain injury die outside intensive care units and could go unrecognized as potential organ donors. We conducted a prospective observational study in seven hospitals in the Netherlands to define the number of unrecognized potential organ donors outside intensive care units, and to identify the effect that end-of-life care has on organ donor potential. Records of all patients who died between January 2013 and March 2014 were reviewed. Patients were included if they died within 72 h after hospital admission outside the intensive care unit due to devastating brain injury, and fulfilled the criteria for organ donation. Physicians of included patients were interviewed using a standardized questionnaire regarding logistics and medical decisions related to end-of-life care. Of the 5170 patients screened, we found 72 additional potential organ donors outside intensive care units. Initiation of end-of-life care in acute settings and lack of knowledge and experience in organ donation practices outside intensive care units can result in under-recognition of potential donors equivalent to 11-34% of the total pool of organ donors. Collaboration with the intensive care unit and adjusting the end-of-life path in these patients is required to increase the likelihood of organ donation.

Unilateral Vocal Cord Paralysis following Insertion of a Supreme Laryngeal Mask in a Patient with Sjögren's Syndrome.

Since its introduction in 1988 by Dr. Archie Brain, the laryngeal mask airway (LMA) is being used with increasing frequency. Its ease of use has made it a very popular device in airway management and compared to endotracheal intubation it is less invasive. The use of LMA was on the rise, so has been the incidence of its related complications. We report severe unilateral vocal cord paralysis following the use of the supreme laryngeal mask (sLMA) in a patient with Sjögren's syndrome. In addition, we propose possible mechanisms of injury, review the existing case reports, and discuss our findings.

Pulmonary blood volume measured by contrast enhanced ultrasound: a comparison with transpulmonary thermodilution.

BACKGROUND: Blood volume quantification is essential for haemodynamic evaluation guiding fluid management in anaesthesia and intensive care practice. Ultrasound contrast agent (UCA)-dilution measured by contrast enhanced ultrasound (CEUS) can provide the UCA mean transit time (MTT) between the right and left heart, enabling the assessment of the intrathoracic blood volume (ITBV(UCA)). The purpose of the present study was to investigate the agreement between UCA-dilution using CEUS and transpulmonary thermodilution (TPTD) in vitro and in vivo. METHODS: In an in vitro setup, with variable flows and volumes, we injected a double indicator, ice-cold saline with SonoVue(®), and performed volume measurements using transesophageal echo and thermodilution by PiCCO(®). In a pilot study, we assigned 17 patients undergoing elective cardiac surgery for pulmonary blood volume (PBV) measurement using TPTD by PiCCO(®) and ITBV by UCA-dilution. Correlation coefficients and Bland-Altman analysis were performed for all volume measurements. RESULTS: In vitro, 73 experimental MTT's were obtained using PiCCO(®) and UCA-dilution. The volumes by PiCCO(®) and UCA-dilution correlated with true volumes; r(s)=0.96 (95% CI, 0.93-0.97; P<0.0001) and r(s)=0.97 (95% CI, 0.95-0.98; P<0.0001), respectively. The bias of PBV by PiCCO(®) and ITBV(UCA) were -380 ml and -42 ml, respectively. In 16 patients, 86 measurements were performed. The correlation between PBV by PiCCO(®) and ITBV(UCA) was r(s)=0.69 (95% CI 0.55-0.79; P<0.0001). Bland-Altman analysis revealed a bias of -323 ml. CONCLUSIONS: ITBV assessment with CEUS seems a promising technique for blood volume measurement, which is minimally-invasive and bedside applicable. CLINICAL TRIAL REGISTRATION: ISRCTN90330260.

[Serious sepsis treatment in intensive care departments in the Czech Republic -  EPOSS Project pilot results]. / Lécba tezké sepse na pracovistích intenzivní péce v Ceské republice -  pilotní výsledky projektu EPOSS.

INTRODUCTION: Severe sepsis is still associated with significant morbidity and mortality, which is however different, as well as its management, depending on the region. What is the situation in the Czech Republic and what is the character of patients with severe sepsis is currently not known. The aim of the project is to describe the processes of care, outcome and characteristics of patients with severe sepsis admitted to the intensive care department of the Czech Republic. METHODS: This is a multicentre and observational project with retrospective enrollment of patients who meet the criteria for severe sepsis before or within 24 hours after admission to selected intensive care units (ICU EPOSS). RESULTS: 394 patients were analyzed. Median age at admission was 66 (56- 76) years, males predominated (58.9%) and the median APACHE II score on admission was 25 (19- 32). Patients were predominantly medical (56.9%) and most were secondary admitted from other ICU (53.6%). Meeting the criteria of severe sepsis was most frequently within the period (± 4 hours) of admission the EPOSS ICU (77.6%). Median total fluid intake during the first 24 hours was 6,680 (4,840- 9,450) ml. Most patients required mechanical ventilation (58.4%). Compliance with the resuscitation bundle of severe sepsis in our group was very good and was associated with lower mortality of patients. Most frequently, the EPOSS ICU length of stay (LOS) was 7 (3- 15) days and median hospital LOS was 13 (8- 28) days. Hospital mortality in our cohort was 35.8%. CONCLUSION: Introducing the project, which in its first stage obtained valuable and internationally comparable data about patients with severe sepsis admitted to the involved ICU in the Czech Republic.

Presence of hypogammaglobulinemia - a risk factor of mortality in patients with severe sepsis, septic shock, and SIRS.

In this retrospective study we assessed the frequency of hypogammaglobulinemia in 708 patients with SIRS, severe sepsis and septic shock. We evaluated the relationship between hypogammaglobulinemia IgG, IgM and 28 day mortality. Total of 708 patients and 1,513 samples were analyzed. In the three subgroups we investigated, patients met the criteria of SIRS, severe sepsis and septic shock. IgG hypogammaglobulinemia was demonstrated in 114 patients with severe sepsis (25.2%), 11 septic shock patients (24.4%), and in 29 SIRS patients (13.9%). IgM hypogammaglobulinemia was documented in 55 patients with severe sepsis (12.2%), 6 septic shock patients (13.3%), and in 17 SIRS patients (8.1%). Mortality of patients with severe sepsis and normal IgG levels was significantly lower (111 patients; 32.8%) compared with those with IgG hypogammaglobulinemia (49 patients; 43.0%; p=0.001). Mortality of patients with septic shock and IgG hypogammaglobulinemia (n=5) was significantly higher compared with those with normal IgG levels (45.5% vs. 38.2%; p=0.001). Mortality of patients with severe sepsis and IgM hypogammaglobulinemia did not differ from that of patients with normal IgM levels (37.0 vs. 41.8%). Mortality of patients with septic shock and IgM hypogammaglobulinemia was significantly higher compared with those with normal IgM levels (50% vs. 38.5%; p=0.0001). This study documented relatively high incidence of hypogammaglobulinemia IgG and IgM in patients with severe sepsis, septic shock and SIRS respectively. The presence of IgG hypogammaglobulinemia in patients with severe sepsis is independent factor of mortality.

Hypotonic and isotonic fluid overload as a complication of hysteroscopic procedures: two case reports.

Hysteroscopy is used extensively for both the diagnosis and treatment of intrauterine pathology. Although considered a safe procedure, complications such as cervical laceration, uterine perforation, absorption of irrigation solutions and, rarely, gas or air embolism may occur. The authors present two cases with successful outcomes, whereby complications following hysteroscopy occurred due to excessive fluid absorption. Hypotonic as well as isotonic distention media can cause serious complications. The authors focus on factors that may increase the risk of fluid overload, which should be known to both anesthesiologists and gynecologists.

[Treatment of invasive candidiasis--recommendations of professional]. / Lécba invazivní kandidózy--doporucení odborných spolecností.

National working group representing clinicians (hematologists, oncologists, infection diseases and ICU specialists), microbiologists, and different special medical societies and working groups prepared evidence-based guidelines for the treatment established fungal infection--invasive candidiasis in the adult hematology and ICU patients. These guidelines updated those published in the Czech Republic in 2003-2004. Evidence criteria of the Infectious Diseases Society of America (IDSA) were used for assessing the quality of clinical trials, and EORTC/MSG Consensus Group for definitions of invasive fungal disease.

[Treatment for invasiveness aspergillosis--recommendations of professionals]. / Lécba invazivní aspergilózy--doporucení odborných spolecností.

An increasing incidence of invasive aspergillosis is observed in most immunocompromised patients, and especially patients with acute leukemia and after hematopoietic stem cell transplantation. In order to decrease the mortality due to this infection, the clinicians need to optimise their treatment choice. The objective of these guidelines is to summarize the current evidence for treatment of invasive aspergillosis. The recommendations have been developed by an expert panel following an evidence-based search of literature with regard to current recommendation of European Conference in Infections in Leukemia and Infectious Diseases Society of America.

[Evaluation of lymphocyte activation in patients in intensive care units by using flow cytometry for determining expression of early activation antigen CD69]. / Hodnocení aktivace lymfocytu sledováním exprese casného aktivacního antigenu CD69 prutokovou cytometrií u pacientu na JIP.

Disorders in immune reactions represent one of the main pathogenetic mechanisms in patients of Intensive Care Units who suffer from sepsis or syndrome of systemic inflammatory response. The determination of early activation sign CD69 on T lymphocytes makes it possible to evaluate functional capacity of this cell population. The determination of other selected immunological parameters contributes to differential diagnosis of infectious and non-infectious etiology of systemic inflammatory response. The authors demonstrated lower expression of CD69 on CD3+ CD8+ lymphocytes after stimulation with phytohemagglutinin in patients with sepsis as well as patients with the syndrome of systemic inflammatory response of non-infections etiology. No statistically significant differences were proved in the concentrations of IgG, IgA and IgM, number of leukocytes, percentual representation of lymphocytes, TNF alpha production and the expression of surface sign of CD64 in both groups of patients. There were statistically significant differences in the concentrations of C3 and C4 components of complement, prealbumin and procalcitonin. The study did not show correlation between the expression of CD69 and selected immunological parameters (IgA, IgM, IgG, C3, C4, leukocytes, lymphocytes, prealbumin, procalcitonin, TNF alpha and CD64).

[Comparison of procalcitonin, interleukin-6 and C-reactive protein in the differential diagnosis of patients with sepsis syndrome in intensive care units]. / Srovnání prokalcitoninu, interleukinu-6 a C-reaktivního proteinu v diferenciální diagnostice pacientu JIP se syndromem sepse.

UNLABELLED: One of the most difficult tasks in differential diagnosis of patients with septic syndrome at the Intensive Care Units is to differentiate between infection and non-infection etiology of this syndrome. In the last years, new parameters have played an important role in this area--C-reactive protein, Interleukin-6 and procalcitonin. THE AIM: Of the investigation was to compare these three parameters in differential diagnosis of the septic syndrome. THE COHORT AND METHODS: The authors examined 56 patients (17 women and 39 men, mean age being 43 and 51 years, respectively) hospitalized at the Intensive Care Units who corresponded to the criteria of the syndrome of inflammatory response, sepsis or septic shock. A total of 99 examinations were done. The samples were taken up to 24 hours after the beginning of clinical symptomatology and submitted to the laboratory within four hours. Immediately afterwards the determination of concentrations of all three parameters--C-reactive protein, interlaukin-6 and procalcitonin, were done. The results of the examinations were compared to each other as well as to the diagnosis of sepsis--the confirmed infection etiology. RESULTS: In all the evaluated parameters the authors detected significant differences between the values of entry examination and all measurements between the patients with the syndrome of systemic inflammatory response and septic shock as well as among patients with sepsis and the septic shock. Likewise, the authors confirmed significant differences between concentrations of all three parameters in comparing the patients with sepsis and those with the septic shock. Only in the case of procalcitonin there was a significant difference in concentration between patients with the syndrome of systemic inflammatory response of non-infectious etiology and those with sepsis. The concentration of procalcitonin was the only predictive marker of diagnosis with the correlation coefficient r = 0.7263, r2 = 0.5275, P < 0.00005. CONCLUSION: Calcitonin proved to be the most specific parameter in demonstrating infection etiology in patients with the septic syndrome, its predictive value being higher than that of C-reactive protein and Interleukin-6. Monitoring of calcitonin dynamism provides important information on efficiency of the applied antibiotic treatment. In patients with diagnostic uncertainties as far as the etiology of the septic syndrome is concerned; procalcitonin is the parameter of choice, while it may be supplemented with the examination of C-reactive protein.