Hepatic Encephalopathy Confirmed by Magnetic Resonance Imaging in a Patient with Unobvious Cause of Chronic Liver Disease Decompensation.

Fifty-four-year old male was admitted to the intensive care unit (ICU) due to impaired consciousness. Past medical history included alcohol dependence, liver cirrhosis, esophageal varices, 2 esophageal varices banding procedures in the past, pathological obesity. Computed tomography (CT) examination of the head performed in the referring hospital was normal. At admission the CT examination of the head was repeated and showed no abnormalities. Urgent esophagogastroduodenoscopy revealed presence of esophageal varices and scarification following previous banding procedures located in the middle and lower part of the esophagus. Gastrointestinal bleeding being the most likely cause of chronic liver decompensation was therefore excluded. Multimodal neurologic diagnostic assessment was negative. Finally magnetic resonance imaging (MRI) of the head was performed. Taking into account clinical picture and the MRI result, the differential diagnosis included chronic liver encephalopathy, exacerbated acquired hepatocerebral degeneration, and acute liver encephalopathy. Due to history of umbilical hernia CT of the abdomen and pelvis was performed and showed intussusception of the ileum, confirming hepatic encephalopathy. In this case report the MRI suggested the diagnosis of hepatic encephalopathy and prompted search for alternative causes of decompensation of chronic liver disease.

Hemodynamic Monitoring by Smartphone-Preliminary Report from a Comparative Prospective Observational Study.

BACKGROUND: Advanced hemodynamic monitoring supports making therapeutic decisions in critically ill patients. New technologies, including mobile health, have been introduced into the hemodynamic monitoring armamentarium. However, each monitoring method has potential limitations-content, technical and organizational. The aim of this study was to assess the comparability between measurements obtained with two arterial pressure cardiac output methods: Capstesia™ smartphone hemodynamic software (CS) and LiDCO Rapid™ uncalibrated hemodynamic monitor (LR). METHODS: The initial analysis included 16 patients in the period 06-09 2020 without limitations that could make the results obtained unreliable. Eighty pairs of cardiac output measurements were obtained. The comparability of cardiac output results obtained with both methods was assessed using the Spearman's rank correlation coefficient (R), the intra-class correlation (CCC) and the Bland-Altman curves analysis (B-A). RESULTS: The median (IQR) cardiac output measured with CS and LR were 4.6 (3.9-5.7) and 5.5 (4.6-7.4) L min-1, respectively. In the B-A analysis, CS cardiac output values were on average 1.2 (95% CI -2.1-4.4) L min-1 lower than LR values. The correlation between cardiac output with CS and LR was moderate (r = 0.5; p = 0.04). After adjusting for the presence of the dicrotic notch on the pulse waveform, in the group of eight patients with a visible dicrotic notch, the CS and LR results differed by only 0.1 (95% CI -0.8-1.1) L min-1, the correlation between CS and LR was close to complete (r = 0.96; p < 0.001), and the percentage error was 40%, with a CCC-CS of 0.98 (95% CI 0.95-0.99). CONCLUSIONS: The CapstesiaTM smartphone software can provide an alternative method of cardiac output assessment in patients meeting arterial pressure cardiac output evaluation criteria with a clearly discernible dicrotic notch on the arterial pulse pressure waveform. It is necessary to confirm the obtained observations on a larger group of patients; however, it may potentially make objective hemodynamic measurements ubiquitous in patients with invasive arterial pressure monitoring with a clearly discernible dicrotic notch.

Basics of mechanical ventilation for non-anaesthetists. Part 1: Theoretical aspects.

The expanding number of chronic respiratory diseases and the new Covid-19 outbreak create an increasing demand for mechanical ventilation (MV). As MV is no longer limited to intensive care units (ICU) and operating rooms (OR), more clinicians should acquaint themselves with the principles of mechanical ventilation. To fully acknowledge contemporary concepts of MV, it is crucial to understand the elemental physiology and respiratory machine nuances. This paper addresses the latter issues and provides insight into ventilation modes and essential monitoring of MV.

Haemogram-Derived Indices for Screening and Prognostication in Critically Ill Septic Shock Patients: A Case-Control Study.

This study aimed (1) to assess the diagnostic accuracy of neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte (PLR), monocyte-to-lymphocyte (MLR) and platelet count-to-mean platelet volume (PLT/MPV) ratios in predicting septic shock in patients on admission to the intensive care unit (ICU) and (2) to compare it with the role of C-reactive protein (CRP), procalcitonin (PCT) and lactate level. We also sought (3) to verify whether the indices could be useful in ICU mortality prediction and (4) to compare them with Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores. This retrospective study covered 138 patients, including 61 subjects with multi-organ failure due to septic shock (study group) and 77 sex- and age-matched controls. Septic patients had significantly higher NLR (p < 0.01) and NLR predicted septic shock occurrence (area under the ROC curve, AUROC = 0.66; 95% CI 0.58-0.74). PLR, MLR and PLT/MPV were impractical in sepsis prediction. Combination of CRP with NLR improved septic shock prediction (AUROC = 0.88; 95% CI 0.81-0.93). All indices failed to predict ICU mortality. APACHE II and SAPS II predicted mortality with AUROC = 0.68; 95% CI 0.54-0.78 and AUROC = 0.7; 95% CI 0.57-0.81, respectively. High NLR may be useful to identify patients with multi-organ failure due to septic shock but should be interpreted along with CRP or PCT. The investigated indices are not related with mortality in this specific clinical setting.

Basics of mechanical ventilation for non-aneasthetists. Part 2: Clinical aspects.

Invasive and non-invasive mechanical ventilation (MV) continues to be the most significant life support method. It is, however, coupled with many risks. Historically, concepts of MV did focus on improving the arterial blood gas results rather than preventing harmful side-effects of positive pressure ventilation. Since then, multiple studies exploring this matter emerged and led to the protective MV concept. The golden mean between assuring the best oxygenation and limiting the ventilator-induced lung injury (VILI) is still a matter of debate. These considerations are especially impactful while treating patients with adult respiratory distress syndrome (ARDS), where the limitation of MV's negative effect is specifically important. This paper explores the protective ventilation concept and clinical implications of the latter.