Results of the severe sepsis registry in intensive care units in Poland from 2003-2009.

BACKGROUND: Severe sepsis remains the most common cause of death in intensive care units (ICUs) according to many epidemiological studies. There are no data in Poland on the extent of severe sepsis cases treated in ICUs. The aim of the study was to analyse the course and outcome of severe sepsis patients treated in Polish ICUs. METHODS: In 2003, the internet-based severe sepsis registry was created as a multicentre observational research project. An online questionnaire was made accessible to ICUs participating in the study. Questionnaires were completed after the discharge of patients and included demographic data, clinical and microbiological information about the cause, course, treatment and outcome of septic patients. All data were given voluntarily and anonymously. RESULTS: During the 7-year period (2003-2009), 4999 cases of severe sepsis were registered for analysis. The mean age of septic patients was 57 years, and the majority of the patients were men (58%). The mean length of stay in the ICU was 10 days. A significant decrease in the mortality rate was observed from 54% in 2003 and 56% in 2004 to 46% in 2009 (P < 0.05). Most of the patients were admitted to the ICU for surgical reasons (56%), and intra-abdominal infections predominated (49%). Severe sepsis patients were admitted to ICUs in critical condition, and the majority of them (89%) had 3 or more organs dysfunction. The APACHE II score on admission was 26 points. Community acquired infections were the most frequent cause of severe sepsis (53%). Most of the pathogens responsible for infection were Gram-negative bacteria (58%). Gram-positive bacteria were identified in 34% of patients and fungi in 16%. A positive blood culture was detected in 41% of patients. Vasopressors were administered to most of the patients (86%). There was a marked increase in the frequency of administering noradrenaline and a decrease in administering dopamine. Renal replacement therapy was applied in 22% of the patients, and there was a marked increase in this type of therapy in the last two years of the study period. CONCLUSIONS: Patients with severe sepsis involved in the 7-year registry were critically ill in half of the cases because of intra-abdominal infections, and the majority of them had multi-organ dysfunction. The mortality of registered patients was high, but it significantly decreased during the observation time. Based on the results obtained from this voluntary registry, the authors conclude that mandated sepsis registries should be established in Polish hospitals to improve the strategy of diagnosing and managing this syndrome.

Bile bacterial flora and its in vitro resistance pattern in patients with acute cholangitis resulting from choledocholithiasis.

INTRODUCTION: Cholangitis and biliary sepsis are severe infectious diseases, which are often observed in patients with choledocholithiasis. The antimicrobial therapy is effective if started as soon as the diagnosis is made. Therefore, the profile of bile pathogens and its susceptibility to a number of antibiotics were evaluated. MATERIAL AND METHODS: Bile cultures and antibiograms from 92 patients hospitalized between January 2006 and December 2008 in a tertiary referral center for the treatment of biliary and pancreatic diseases (Central Teaching Hospital, Medical University of Silesia) were reviewed. Specimens were obtained from patients with acute cholangitis and confirmed choledocholithiasis during endoscopic (i.e. ERCP) and surgical (i.e. percutaneus transhepatic biliary drainage) procedures. The bile specimens were examined for pathogenic aerobic and anaerobic bacteria and fungi. RESULTS: Sixty-five of 92 analyzed cultures were positive. A total of 69 pathogens were isolated: 47 (68.1%) gram-negative bacteria, 18 (26.1%) gram-positive bacteria, 2 (2.9%) anaerobes and 2 (2.9%) Candida. The predominant gram-negative pathogens were Escherichia coli, Acinetobacter baumani complex, Klebsiella pneumoniae and Enterobacter cloacae. The most effective antibiotics against gram-negative bacteria were imipenem, cefoperazone/sulbactam, piperacillin/tazobactam and cefepime (susceptibility 97.9%, 89.4%, 85.1% and 85.1%, respectively). The expenditure on antibiotics monotherapies and combined therapies was also analyzed. CONCLUSION: Our study shows that gram-negative bacteria were the predominant bile pathogens found in patients with acute cholangitis. Piperacillin/tazobactam or ceftazidime may be the alternative to ciprofloxacin therapeutic option. The addition of ticarcillin/clavulanic acid to ciprofloxacin could also be considered. However, imipenem should remain a back-up antibiotic in the treatment of acute cholangitis.

[Open versus percutaneous repair of abdominal aortic aneurysm]. / Skutecznosc i bezpieczenstwo znieczulenia miejscowego z analgosedacja w wewnatrznaczyniowej chirurgii tetniaka aorty brzusznej.

BACKGROUND: The mortality in aortic abdominal aneurysm surgery remains in the 2-7% range. The aim of the study was to compare the results and safety of surgical aneurysm resection with grafting under general anaesthesia, using percutaneous insertion of a stent under local anaesthesia and intravenous analgesic sedation. METHODS: The data from patients scheduled for elective subrenal abdominal aortic treatment was analysed retrospectively. Patients were allocated to two groups, according to their general condition, ASA status, presence of other pathologies and anatomical conditions. Patients in group I underwent open surgery with general anaesthesia; patients in group II received stents implanted using local anaesthesia and intravenous analgesic sedation. RESULTS: One houndred twenty-seven patients were allocated either to group I (n=87) or to group II (n=40). Blood pressure, heart rate, the need for catecholamines, blood loss and fluid replacement were all higher in group I. More than 50% of patients from this group required mechanical ventilation in the early postoperative period, as well as longer hospitalization. All patients in group II survived, while 6 patients from group I died from postoperative complications. CONCLUSIONS: Endovascular repair of aortic abdominal aneurysms under local anaesthesia combined with i.v. sedation is a safe alternative in high-risk patients.

[Effectiveness and safety of unilateral spinal anaesthesia]. / Efektywnosc i bezpieczenstwo jednostronnego znieczulenia podpajeczynówkowego.

BACKGROUND: The purpose of the study was to evaluate the effectiveness and safety of unilateral spinal anaesthesia and to compare this technique to the commonly used bilateral technique in a prospective, controlled, randomized study. METHODS: Fifty-four ASA I-III adult patients, of both sexes, aged 18-75 years, and scheduled for elective unilateral surgery, were randomly allocated into two groups: a unilateral spinal anaesthesia group (group B, n=27, to receive 0.5% hyperbaric bupivacaine, 1.2 mL+0.1 mL per every 10 cm over 170 cm height); and a bilateral spinal anaesthesia group (group K, n=27, to receive 0.5% bupivacaine 2.4 mL+0.2 mL per every 10 cm over 170 cm height). The statistical analysis included haemodynamic parameters and side-effects. The t-test for independent trials, test for two structure indexes and chi2 test were used. RESULTS: All blocks were fully effective. Mean arterial blood pressure was significantly lower in the K group. Heart and respiratory rates did not differ between the groups. The total number of side effects (hypotension, bradycardia, apnoea) requiring intervention was similar in both groups. CONCLUSION: Unilateral spinal anaesthesia is safe. The dose of bupivacaine is lower and haemodynamic stability is better. The technique is more time consuming, compared to standard spinal anaesthesia and the patient's cooperation is essential.

[Surfactant protein D as a biomarker for lung injury]. / Bialko D surfaktantu jako biomarker uszkodzenia pluc.

Respiratory distress and the need for mechanical ventilation, have been the most common reasons for ITU hospitalization. Pulmonary pathology is sometimes difficult to diagnose and differentiate; therefore we are on a continuous search for diagnostic tools and markers. It has been suggested that in patients intubated for acute lung injury, lower concentrations of surfactant proteins A and D in bronchoalveolar fluid and higher concentrations in the plasma are associated with more severe lung injury and worse clinical outcomes. Surfactant protein D (SP-D) plays a crucial role in defense mechanisms and immunomodulation, binding with various pathogens such as bacteria, fungi and viruses. SP-D is a valuable marker in ARDS and other specific and non-specific pulmonary pathologies, and may find a place as a valuable marker of the severity of disease.

[Cathether related blood stream infection in ICU patients with prolonged central venous catheterisation--cause and prevention]. / Przyczyny i zapobieganie zakazeniom u chorych po zalozeniu cewnika do duzych naczyn krwionosnych.

UNLABELLED: Colonization of the tip of the intravenous catheter is often observed in the ICU practice and can be the source of dangerous bacteriemia (CRBSI--catheter related bloodstream bacteraemia) and sepsis with multiorgan failure. There are many cases conected with bacterial colonization of the tip of the catheter in the ICU practice, which could be the source of dangerous bacteriemia--CRBSI (catheter related bloodstream bacteriemia) and sepsis with organs failure. MATERIAL AND METHODS: 105 patients with sepsis were examined, which clinical state pointed, that CVC was the source of infection. We removed the CVC in this patient, and its tip and patient's blood were examined microbiologically. In the case of positive result, the antibiogram was made. OBJECTIVE: Evaluation of colonisation and infections of central venous catheters and catheter related blood stream infections (CRBSI) in general ICU patients' and with identification of most frequent microorganisms and their antibiotic sensibility. Results. After examining of 105 samples in 37 (35, 24%) cases we did not culture bacteria. From the rest of 68 (64, 76%) samples we cultured 110 bacterial colonies. 8 of them were admitted to be contaminated samples. 60 tips of the catheter were used to proper analysis from which we isolated 102 bacterial colonies: 44 (43.1%) Gram positive cocci, 32 (31.5%) Enterobacteriaceae, 23 (22.5%) glucose non-fermentative gram-negative rods rods Gram negative non glucose fermentation and 3 (2.9%) fungi (C. albicans). We analized 60 blood samples that derived from patients with confirmed catheter colonisation. It was found that 8 blood samples indicated bacteriemia, but only in 2 cases isolated bacteria came from the CVC. Conclusions. (1) The majority of central venous catheters on ICU are colonized by pathogenic microorganisms. (2) Aerobic Gram positive and Gram negative bacteria are responsible for CVCs' infection. (3) Bacterial colonization of CVCs' is not very often the reason of CRBSI. (4) Prolonged use of central venous catheters needs careful prophylactic standards of an microbiological monitoring.

Results of severe sepsis treatment program using recombinant human activated protein C in Poland.

BACKGROUND: Recombinant human activated protein C (drotrecogin alfa [activated]--DAA) demonstrated in Phase III controlled clinical studies significant reduction of mortality in patients with severe sepsis and high risk of death. The aim of the study was to assess the therapeutic efficacy of DAA in patients included in the National Severe Sepsis Register in Poland. MATERIAL/METHODS: The analysis included 3233 cases of severe sepsis reported between 04.2003 and 11.2005. 302 patients (9.3%) were treated with DAA. The clinical course of the disease in DAA and non-DAA treatment groups was compared. Logistic regression models for the effects of independent variables on the risk of death (dependent variable) were developed. RESULTS: In the patients treated with DAA, the relative risk of death was lower by 31% than in those who were not treated. In a multivariate logistic regression model, the use of DAA was, independently of the patient's age, severity of the clinical condition and type of organ dysfunction, the most significant mortality-reducing factor in severe sepsis. CONCLUSIONS: The use of DAA in the treatment of severe sepsis proved to be a very effective method of mortality reduction. Controlled nationwide surveillance program contributed to its effective utilization. The National Severe Sepsis Register proved to be a very useful instrument for assessment of the course of the disease and treatment efficacy.

[Rhabdomyolysis, disseminated intravascular coagulation and acute renal failure after severe narcotics intoxication (MDMA, THC, amphetamine)]. / Rabdomioliza, rozsiane krzepniecie wewnatrznaczyniowe i ostra niewydolnosc nerek po ostrym zatruciu srodkami odurzajacymi (MDMA, THC, amfetamina).

More often we are faced with the cases of young people (who are in a serious condition) who land in ICU, because of severe narcotics intoxication, which they took occasionally on the concerts, discotheques and social events. From 1997 we observed rapid increase of admission to hospitals due to amphetamine, MDMA (2,3-methylenedeoxymethamphetamine which is a main component of a tablet called ecstasy) and THC (9-d tetrahydrocannabinols which are a component of sunn hemps) intoxication and decrease of opioid's poisoning. 23 years old patient was admitted to ICU in critical condition after severe narcotics intoxication. Patient was deeply unconscious (GCS 3) with tetraplegia and high temperature (39.6 degrees C). He had endotracheal tube (artificially ventilated) and hypovolemic shock with circulatory insufficiency (blood pressure was supported by 3 catecholamines). We observed many petechias and ecchymoses which suggested vascular haemorrhagic diathesis. It was found that the patient had disseminated intravascular coagulation and rhabdomyolysis with acute renal failure which was treated by dialysis. After 26 days of intensive treatment the patient was conscious, he had also efficient circulatory and respiratory system but with slight improvement of neurological state. In this condition he was admitted on nephrology ward to continue the treatment and start rehabilitation. The presence of high concentration of amphetamine, MDMA and THC in blood, extreme dehydration and electrolytes disturbances caused rhabdomyolysis, DIC syndrome and acute renal failure which make the prognosis worse and complicate the treatment. Estimating probability of death of this patient in SAPS II scale (Simplified Acute Physiology Scale) he has bad prognosis (86 points gives 95% of death probability). The patient is alive (what is a big success), probably thanks to quick arrival to specialized medical centre and dialysis treatment which was started early.

[Clinical usefulness of gastric tonometry in anesthesiology and intensive care medicine]. / Przydatnosc kliniczna tonometrii zol4dkowej w anestezjologii i intensywnej terapii.

Gastric tonometry is relatively non-invasive technique to assess gastric perfusion and to monitor oxygen metabolism in visceral system. The technique utilizes the PCO2 of the gastric fluid to calculate intramucosal pH (pHi). The calculation is assessed by a modified Henderson-Hasselbalch equation. The combination of a high intramural PCO2 and mucosal acidosis may result from decreased splanchnic perfusion. The values of pHi and regional PCO2 (PrCO2) based on gastric tonometry reflect indirect index of visceral blood flow. In clinical practice the PCO2 of the gastric fluid is collected from saline sampled in the penetrable by carbon dioxide balloon. The silicon balloon is a part of tonometric probe placed in the gastric lumen. Device TONOCAP (Datex-Ohmeda, Helsinki, Finland) allows for full automatic measurement of the carbon dioxide regional pressure (PrCO2). Presented experimental and clinical studies confirmed the usefulness of gastric tonometry in visceral blood perfusion assessment during perioperative and critical ill stage. Finally, the technique allows to decrease the number of complications, treatment expenses and mortality.

[Comparison of technical aspects of colonoscopy in various gastroenterologic centres]. / Porównanie aspektów technicznych kolonoskopii w róznych osrodkach gastrologicznych.

There are ongoing multicenter European trials analyzing, among other factors, technical aspects of colonoscopy in various countries. The aim of the study was to compare the techniques of preparation and performance of colonoscopy in the Department of Gastroenterology at Medical University of Silesia in Katowice and other gastroenterology centers throughout Europe. The trial was conducted between January 1st 2001 and May 30th 2001 in 18 centers in 9 European countries. 307 consecutive patients, who signed consent forms, were recruited in Katowice, while 5697 patients were enrolled in other centers. The data were collected in a dedicated sheet, prepared in the coordinating center in Lausanne (Switzerland). The part concerning methods of bowel preparation was filled in before colonoscopy and the remaining questions (sedation, number of persons involved, duration, completeness, diagnosis, complications) were answered after the procedure. The data from all centers were analyzed in Lausanne and the results were sent back to the participants. The comparison of results from Katowice and other centers was performed in Katowice. We found out, that the type of cleansing the gut did not influence the quality of bowel preparation. Colonoscopy was performed under deep sedation (in the presence of anesthesiologist and anesthesiology nurse) more frequently in Katowice than in other centers. Differences between Katowice and the rest of centers in the other technical aspects of colonoscopy were of minor importance.

Survival after out-of-hospital cardiac arrests in Katowice (Poland): outcome report according to the "Utstein style".

The purpose of this study was to evaluate the outcome of out-of-hospital cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) in the city of Katowice, Poland, during a period of 1 year prior to the planned reorganization of the national emergency system. Data were collected prospectively according to a modified Utstein style. To ensure accurate data collection, a special method of reporting resuscitation events with the use of a tape-recorder was introduced. Patients were followed for a 1-year period. Between 1 July 2001 and 30 June 2002, out-of-hospital cardiac arrest was confirmed in 1153 patients. Cardiopulmonary resuscitation was attempted in 188 patients. Cardiac arrest of presumed cardiac aetiology (147) was bystander witnessed in 105 (71%) cases and lay-bystander basic life support was performed in 35 (24%). In the group of bystander witnessed arrest ventricular fibrillation (VF) or tachycardia was documented in 59, asystole in 40 and other non-perfusing rhythms in six patients. Of 147 patients with cardiac aetiology, return of spontaneous circulation (ROSC) was achieved in 64 (44%) patients, 15 (10%) were discharged alive and 9 (6%) were alive 1 year later. Most of these patients had a good neurological outcome. Time to first defibrillatory shock was significantly shorter for survivors (median 7 min) compared to non-survivors (median 10 min). The most important resuscitation and patient characteristics associated with survival were VF as initial rhythm, arrest witnessed, and lay-bystander CPR.