Protocol for a prospective cohort study on the use of clinical nutrition and assessment of long-term clinical and functional outcomes in critically ill adult patients.

BACKGROUND AND AIMS: Limited data are available on the impact of clinical nutrition over the course of critical illness and post-discharge outcomes. The present study aims to characterize the use of nutrition support in patients admitted to European intensive care units (ICUs), and its impact on clinical outcomes. Here we present the procedures of data collection and evaluation. METHODS: Around 100 medical, surgical, or trauma ICUs in 11 countries (Austria, Belgium, Czech Republic, Germany, France, Hungary, Italy, Poland, Spain, Sweden, United Kingdom) participate in the study. In defined months between November 2019 and April 2020, approximately 1250 patients are enrolled if staying in ICU for at least five consecutive days. Data from ICU day 1-4 are collected retrospectively, followed by a prospective observation period from day 5-90 after ICU admission. Data collection includes patient characteristics, nutrition parameters, complications, ICU and hospital length of stay, discharge status, and functional outcomes. For data analysis, the target is 1000 patients with complete data. Statistical analyses will be descriptive, with multivariate analyses adjusted for potential confounders to explore associations between nutritional balance and change in functional status, time-to-weaning from invasive mechanical ventilation, time to first clinical complication, and overall 15, 30 and 90-day survival. ETHICS AND DISSEMINATION: This non-interventional study was reviewed and approved by the ethics committee of the Medical University Vienna, Vienna, Austria (approval number 1678/2019), and the respective ethical committees from participating sites at country and/or local level, as required. Results will be shared with investigators on a country level, and a publication and results presentation at the 2021 ESPEN Congress is planned. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04143503.

Risk of anal incontinence in women with inflammatory bowel diseases after delivery.

AIM: The aim of our prospective study was to evaluate the development of postpartum anal incontinence in patients with inflammatory bowel disease (IBD) compared to healthy women. MATERIAL AND METHODS: Patients with IBD and healthy controls enrolled in the study from January 1st 2013 to November 30th 2016 and filled in the anal incontinence questionnaire in the beginning of pregnancy and after vaginal delivery. The results were statistically processed using suitable tests. RESULTS: A total of 57 women were enrolled, 17 (29.8 %) with ulcerative colitis, 23 (40.4 %) with Crohn's disease, and 17 (29.8 %) healthy controls. Incidence of postpartum anal incontinence is comparable across all groups; there was no statistically significant difference between the IBD and control groups (Kruskal-Wallis test by ranks with Dunn correction, non-significant). Postpartum anal incontinence was strongly correlated with the extent of perineal injury (r = 0.80; p < 0.0001; Pearson's linear correlation). CONCLUSIONS: Women with inflammatory bowel disease in remission do not exhibit higher incidence of postpartum anal incontinence (PPAI) compared to healthy controls; the key correlate of PPAI appears to be the extent of obstetric injury, consistently across all study groups. These results suggest that concerns about postpartum anal incontinence development should not be an indication for Caesarean section in IBD patients (Tab. 6, Fig. 1, Ref. 34).

Intra-breath arterial oxygen oscillations detected by a fast oxygen sensor in an animal model of acute respiratory distress syndrome.

BACKGROUND: There is considerable interest in oxygen partial pressure (Po2) monitoring in physiology, and in tracking Po2 changes dynamically when it varies rapidly. For example, arterial Po2 ([Formula: see text]) can vary within the respiratory cycle in cyclical atelectasis (CA), where [Formula: see text] is thought to increase and decrease during inspiration and expiration, respectively. A sensor that detects these [Formula: see text] oscillations could become a useful diagnostic tool of CA during acute respiratory distress syndrome (ARDS). METHODS: We developed a fibreoptic Po2 sensor (<200 µm diameter), suitable for human use, that has a fast response time, and can measure Po2 continuously in blood. By altering the inspired fraction of oxygen ([Formula: see text]) from 21 to 100% in four healthy animal models, we determined the linearity of the sensor's signal over a wide range of [Formula: see text] values in vivo. We also hypothesized that the sensor could measure rapid intra-breath [Formula: see text] oscillations in a large animal model of ARDS. RESULTS: In the healthy animal models, [Formula: see text] responses to changes in [Formula: see text] were in agreement with conventional intermittent blood-gas analysis (n=39) for a wide range of [Formula: see text] values, from 10 to 73 kPa. In the animal lavage model of CA, the sensor detected [Formula: see text] oscillations, also at clinically relevant [Formula: see text] levels close to 9 kPa. CONCLUSIONS: We conclude that these fibreoptic [Formula: see text] sensors have the potential to become a diagnostic tool for CA in ARDS.

[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.

Porcine model of ruptured abdominal aortic aneurysm repair.

OBJECTIVES: To validate a porcine model of ruptured abdominal aortic aneurysm (rAAA) repair. DESIGN: Experimental study. METHODS: Ten experimental and five sham-operated pigs were studied. Instrumentation for cardiac output (CO) measurement, regional blood flow (renal-REN and portal-PORT) and blood sampling (inferior vena cava (IVC), renal and portal vein) was done. Microcirculation was visualised sublingually and in ileostoma. PROTOCOL: simulation of rAAA with bleeding (mean arterial pressure (MAP) 45 mmHg) and increased abdominal pressure (25 mmHg) for 4 h; 2 h of infrarenal clamp with shed blood retransfusion; 11 h of post-surgery care. RESULTS: Six experimental pigs completed the protocol and are presented. Bleeding decreased CO to 95%, PORT to 80% and REN to 10% of baseline. From clamping on CO and PORT increased above baseline whereas REN (47%) with creatinine clearance remained compromised till the end. Microcirculation was affected more in ileum than sublingually. Approximately threefold increase in cytokines (tumour necrosis factor-α (TNF-alpha), interleukin (IL)-6 and IL-10) and oxidative stress markers (thiobarbituric acid-reactive substances (TBARs) and 4-hydroxy-2-trans-nonenal (HNE) was observed. Only mild increase in IL-6 and TBARs was observed in sham-operated animals. Organ histology did not reveal differences between groups. CONCLUSIONS: This near-lethal model of rAAA induced expected severe deterioration of haemodynamics and metabolism accompanied with a moderate inflammatory and oxidative stress response.

A 24-h work shift in intensive care personnel: biological pathways between work stress and ill health.

This study evaluated inflammatory, coagulation and microvascular responses to a continuous 24-h work day in 13 healthy intensive care physicians. Inflammatory markers (interleukin [IL]-2, IL-6, IL-10, tumour necrosis factor-α, matrix metalloproteinase [MMP]-9 and adiponectin), adhesion molecules (vascular cellular adhesion molecule-1 and intercellular adhesion molecule-1 [ICAM-1]), coagulation parameters (thrombin-anti thrombin, von Willebrand factor and tissue factor) and sublingual micro circulation were assessed before and after a 24-h work shift. The 24-h work shift had no effect on inflammatory markers and ICAM-1. Direct visualization of micro-circulation did not reveal stress-related perfusion abnormalities. A 24-h work shift in the intensive care unit was associated with significantly increased plasma levels of tissue factor - a potentially important mechanism linking acute job strain, haemostasis and atherosclerosis. The long-term consequences warrant further evaluation.

Tissue concentrations of vasoactive intestinal peptide are affected by peritonitis-induced sepsis and hemofiltration in pigs.

Vasoactive intestinal peptide (VIP) is a neuropeptide released from the autonomic nerves exerting multiple antiinflammatory effects. The aim of the present study was to investigate the impact of severe sepsis and hemofiltration in two settings on plasma and tissue concentrations of VIP in a porcine model of sepsis. Thirty-two pigs were divided into 5 groups: 1) control group; 2) control group with conventional hemofiltration; 3) septic group; 4) septic group with conventional hemofiltration; 5) septic group with high-volume hemofiltration. Sepsis induced by faecal peritonitis continued for 22 hours. Hemofiltration was applied for the last 10 hours. Hemodynamic, inflammatory and oxidative stress parameters (heart rate, mean arterial pressure, cardiac output, systemic vascular resistance, plasma concentrations of tumor necrosis factor-alpha, interleukin-6, thiobarbituric acid reactive species, nitrate + nitrite, asymmetric dimethylarginine) and the systemic VIP concentrations were measured before faeces inoculation and at 12 and 22 hours of peritonitis. VIP tissue levels were determined in the left ventricle, mesenteric and coronary arteries. Sepsis induced significant increases in VIP concentrations in the plasma and mesenteric artery, but it decreased peptide levels in the coronary artery. Hemofiltration in both settings reduced concentrations of VIP in the mesenteric artery. In severe sepsis, VIP seems to be rapidly depleted from the coronary artery and, on the other hand, upregulated in the mesenteric artery. Hemofiltration in both settings has a tendency to drain away these upregulated tissue stores which could result in the limited secretory capacity of the peptide.

New developments in septic acute kidney injury.

The kidney is a common "victim organ" of various insults in critically ill patients. Sepsis and septic shock are the dominant causes of acute kidney injury, accounting for nearly 50 % of episodes of acute renal failure. Despite our substantial progress in the understanding of mechanisms involved in septic acute kidney injury there is still a huge pool of questions preclusive of the development of effective therapeutic strategies. This review briefly summarizes our current knowledge of pathophysiological mechanisms of septic acute kidney injury focusing on hemodynamic alterations, peritubular dysfunction, role of inflammatory mediators and nitric oxide, mitochondrial dysfunction and structural changes. Role of proteomics, new promising laboratory method, is mentioned.

[24-year old male with fever, multi-organ dysfunction and fast progressing ARDS]. / 24letý muz s horeckami, multiorgánovou dysfunkcí a rychle progredujícím ARDS.

A 24-year-old man presented with cough, sore throat, fever, maculopapulous exanthema, pericardial and pleural effusion. Despite extensive evaluation neither infectious, autoimmune, hematological nor oncological disorders were revealed. Broad spectrum antibiotic and subsequently corticosteroid treatment failed to resolve the symptoms. Multiorgan failure with rapid progress of acute respiratory distress syndrome and circulatory failure developed and patient died. Adult onset Still's disease (AOSD), a diagnosis considered in this patient, is a rare disease with unknown prevalence, pathogenesis and etiology. Clinically it is characterized by spiking fever, arthritis, rash, and impairment of multiple organs. There is no single diagnostic test for AOSD. Rather, the diagnosis is based on the clinical criteria and requires the exclusion of infectious, neoplastic, and other autoimmune diseases. Rarely the course of the disease can be rapidly progressive to death. Treatment includes the use of non-steroid antirheumatic drugs and corticosteroids. Limited data suggest that biological agents (e.g. anti-TNF-alpha, anti-IL-1), rituximab or intravenous immunoglobulins might be promising for the treatment of severe cases.

Cytokines and liver regeneration after partial portal vein ligation in porcine experimental model.

THE AIM OF STUDY: The limits of liver surgery are restricted today by the functional reserves of remnant parenchyma. The aim of this article was to acquaint the general surgical and medical public with the results of experimental liver regeneration stimulated by cytokines and thus to enhance their effort to carry on with implementing the research results in clinical practice. METHODS: Authors present their experimental model of liver regeneration after ligation of portal branches for caudate and right lateral, and right medial liver lobes. The regeneration was induced by application of TNF-alpha and IL-6 into the non-occluded portal branches, and compared with the results of other experimental teams. RESULTS AND CONCLUSION: The absolute volume of hypertrophic lobes increases after application of TNF-alpha more rapidly, whereas in the control group, practically no changes were recorded in hypertrophic liver lobes volumes in first three days. The achieved acceleration of growth of hypertrophic liver lobes after application of TNF-alpha and IL-6 confirmed the key role of studied pleiotropic cytokines in the priming of liver parenchyma regeneration after portal vein ligation (Fig. 3, Ref. 26).

[Persistent diarrhoea, hypotension, polyneuropathy]. / Perzistentní prujmy, hypotenze a polyneuropatie.

We present a case report of a 59-year-old man with a history of arterial hypertension and excision of malignant melanoma. He was admitted to the hospital because of two months history of diarrhoea, weight loss and circulatory collapse. In addition, the patient suffered from marked vegetative instability with symptomatic hypotension, polyneuropathy and progression of renal insufficiency, without proteinuria. Complex examination did not reveal neoplasms, endocrine, autoimmune, infectious or neurodegenerative disorders. A serial biopsy of colon failed to provide a clue to the diagnosis. However, AA amyloidosis was found on the kidney biopsy. Neither chronic inflammation nor malignancy was revealed and, hence, no causal treatment could have been established. The patient died from multiple organ failure. The autopsy confirmed systemic AA amyloidosis. The triad consisting ofdiarrhoea, polyneuropathy and hypotension should rise the suspicion on amyloidosis.

[Hemopurification in sepsis: current view]. / Hemoeliminacní metody v lécbe sepse: soucasný stav.

Sepsis is the leading cause of mortality in non-coronary intensive care units. The uncontrolled and deregulated systemic inflammatory response to infection plays a central role in the pathophysiology of sepsis. This response is mediated by a broad spectrum of endogenous mediators leading to dysfunction in multiple organs remote from the primary infectious site. The failure of numerous clinical trials aimed at eliminating a single mediator stimulated the research to focus on non-selective removal of excessively produced mediators of sepsis. This "detoxification" forms the theoretical basis and biological rationale for the use of hemopurification therapies as an adjunctive treatment of sepsis. Our article reviews the current evidence of hemopurification methods in the supportive treatment of sepsis, briefly discusses new trends and summarizes the recommendations for clinical practice.

Negative association between plasma levels of adiponectin and polychlorinated biphenyl 153 in obese women under non-energy-restrictive regime.

The aim of this study was to reveal whether accumulation of the persistent organic pollutants (POPs), especially polychlorinated biphenyl (2,2',4,4',5,5'-hexachlorobiphenyl, PCB 153), affects plasma levels of adiponectin in obese patients. The study was designed as a longitudinal intervention trial with a control group, where 27 obese women (body mass index (BMI)>30 kg/m(2); age 21-74 years) were studied before (OB) and after (OB-LCD) a 3-month low-calorie-diet intervention (LCD; 5 MJ daily). As the control group, 9 female volunteers without LCD intervention were used (C; BMI=19-25 kg/m(2); age 21-64 years). Plasma levels of PCB 153 were measured by high-resolution gas chromatography with electron capture detection; total adiponectin and insulin plasma levels were quantified by immunoassays; and adiponectin multimeric complexes were quantified by immunoblotting. Plasma levels of total adiponectin, high and medium molecular weight multimers significantly negatively correlated with plasma levels of PCB 153 in OB, but not in C or in OB-LCD, whereas the LCD intervention lowered BMI by 3.3+/-3.0 kg/m(2). Our results may suggest suppression of adiponectin by PCB 153 in obese women under non-energy-restrictive regime, which may contribute to the known association of PCB 153 and other POPs with type 2 diabetes.

[Feedings of critical care patients by endoscopic three-luminal tube--a retrospective analysis]. / Výziva kriticky nemocných endoskopicky zavádenou trojluminální sondou--retrospektivní analýza.

BACKGROUND: Enteral nutrition (EN) represents a preferred type of nutritional support in critical care patients, in spite of the high incidence of intolerance. One of the methods which can speed up the delivery of adequate amounts of food is to switch from the gastric to post-pyloric feeding. A three-luminal tube (TLT) enables post-pyloric enteral feeding with accompanying gastric decompression. The aim of our study was to evaluate effectiveness and safety of the endoscopically introduced TLT along with the estimation of the adequate dose of enteral nutrition. METHODS AND RESULTS: Retrospective analysis of 111 critical care patients with 140 introduced TLT during 2003 to 2006 in two intensive care units (UIC) in the Teaching hospital in Plzen included patients of average age 54 years (+/- 15), APACHE II score 26 (+/- 10) and UIC mortality was 24%. Eight introductions were technically not successful (6%). Reintroduction of the tube was necessary in 21 patients (19%). The average time of tube introduction was 6 minutes (+/- 3). In direct relation to endoscopy no serious complication was observed. In our cohort, 34 ventilator-associated pneumonias developed (31%). Average time interval since the admission to the hospital till TLT introduction was 7 days (+/- 6). Evaluation of a subgroup of 77 patients from one UIC has shown that the adequate amount of EN was achieved in 82% of patients in 4 days (+/- 3) after the TLT introduction. In average, TLT was introduced for 11 days (+/- 7). CONCLUSIONS: Endoscopic TLT introduction represents a safe and reliable method which can ensure adequate amount of enteral nutrition in majority of critical care patients with gastrointestinal dysfunction. In our conditions, TLT is probably not sufficiently used.

Perfusion pressure manipulation in porcine sepsis: effects on intestinal hemodynamics.

Limited information is available about selection of the threshold for arterial blood pressure in critically ill patients, particularly in sepsis when normal organ blood flow autoregulation may be altered. The present experimental study investigated whether increasing perfusion pressure using norepinephrine in normotensive hyperdynamic porcine bacteremia affects intestinal macro- and microcirculation. Nine pigs received continuous i.v. administration of Pseudomonas aeruginosa (PSAE) to develop hyperdynamic, normotensive (mean arterial pressure [MAP] 65 mm Hg) sepsis. Norepinephrine was used to achieve 10-15 % increase in MAP. Mesenteric arterial blood flow (Q(gut)), ileal mucosal microvascular perfusion (LDF(gut)) and ileal-end-tidal PCO(2) gap (PCO(2) gap) were measured before norepinephrine, after 60 min of norepinephrine infusion and 60 min after norepinephrine infusion had been discontinued. During a 12 h period of PSAE infusion all pigs developed hyperdynamic circulation with significantly decreased MAP. Although the mesenteric blood flow remained unchanged, infusion of PSAE resulted in a gradual fall of ileal microvascular perfusion, which was associated with progressively rising PCO(2) gap. Norepinephrine which induced a 10-15 % increase in perfusion pressure (i.e. titrated to attain near baseline values of MAP) affected neither Q(gut) nor the intestinal blood flow distribution (Q(gut)/CO). Similarly, norepinephrine did not change either LDF(gut) or PCO(2) gap. In this hyperdynamic, normotensive porcine bacteremia, norepinephrine-induced increase in perfusion pressure exhibited neither beneficial nor deleterious effects on intestinal macrocirculatory blood flow and ileal mucosal microcirculation. The lack of changes suggests that the gut perfusion was within its autoregulatory range.

Fluid challenge in patients at risk for fluid loading-induced pulmonary edema.

BACKGROUND: This study evaluated the effects of protocol-guided fluid loading on extravascular lung water (EVLW) and hemodynamics in a group of patients at high risk for volume expansion-induced pulmonary and systemic edema. METHODS: Nine acutely admitted septic patients with acute lung injury (ALI) were prospectively studied. In addition to sepsis and ALI, the following criteria indicating increased risk for edema formation had to be fulfilled: increased vascular permeability defined as microalbuminuria greater than fivefold normal and hypoalbuminemia < 30 g l(-1). Two hundred-ml boluses of a 10% hydroxyethyl starch (HES) was titrated to obtain best filling pressure/stroke volume relation. Extravascular lung water and intrathoracic blood volume (ITBV) were measured using a transpulmonary double-indicator dilution technique. Baseline data were compared with data at the end of fluid loading and 3 h postchallenge. RESULTS: At study entry the mean EVLW was 13 ml kg(-1), and the mean EVLW/ITBV ratio (indicator of pulmonary permeability) was 0.72 (normal range 0.20-0.30). To attain optimal preload/stroke volume relation 633 +/- 240 ml of HES was needed. Fluid loading significantly increased preload (CVP, PAOP and ITBV), and stroke volume. Effective pulmonary capillary pressure (Pcap) rose only slightly. As a result, the Pcap-PAOP gradient decreased. Despite increased cardiac output, EVLW did not change by plasma expansion. CONCLUSION: In this selected group of at-risk patients, the optimization of cardiac output guided by the concept of best individual filling pressure/stroke volume relationship did not worsen permeability pulmonary edema.