Comparative characteristics of some methods for estimating energy expenditure in critically ill mechanically ventilated patients.

AIM: To compare the energy expenditure (EE) assessed by ventilator-derived carbon dioxide production (EE-VCO2-ventilator) and the energy expenditure calculated from six predictive equations with the gold standard energy expenditure measured with indirect calorimetry (IC) in mechanically ventilated patients.

Ehlers-Danlos Syndrome Type IV - Anaesthetic Considerations.

Ehlers-Danlos syndrome (EDS) is a rare disorder that occurs due to genetic defect in the collagen synthesis. The vascular subtype of EDS (type IV) is defined by characteristic facial features, translucent skin, easy bruising, and spontaneous arterial rupture and visceral perforation of such organs as the uterus and intestines, with possible life-threatening consequences. We report a case of a 15-year-old male patient with no past medical history undergoing emergency laparotomy after a spontaneous sigmoid colon perforation. Post-operatively and during the ICU stay complications developed and several revision operations and invasive procedures were necessary. A chest CT angiography revealed a right subclavian artery aneurysm, which was treated by an endovascular stent grafting. Taking into consideration the family history and clinical presentation EDS type IV was discussed as a possible cause of the patient's condition. DNA analysis confirmed the diagnosis. Due to the lack of evidence-based recommendations the anaesthetic management of these patients is still challenging.

Surgical treatment of pneumothorax in patients with COVID-19 - results and management.

INTRODUCTION: The new coronavirus, SARS-CoV-2, provokes infection with different clinical presentation. It involves an asymptomatic condition, mild variants with fever and dry cough to severe pneumonia, adynamia and respiratory failure with lethal outcome. The fibrotic lung tissue after the inflammatory process is a background for development of a secondary pneumothorax. Although it rarely causes lethal outcomes in COVID-19 patients, pneumothorax requires early diagnosis and adequate treatment to prevent any complications and decrease mortality rate. AIM: The aim of this study was to analyse the results of surgical treatment of hospitalized COVID-19 patients with pneumothorax in terms of demographic data, concomitant diseases, complications, and outcome. MATERIALS AND METHODS: Longitudinal prospective study was carried out with 26 patients with pneumothorax as a result of SARS-CoV-2 infection. They were treated at the Intensive Care Unit of the Infectious Disease Clinic and at the Second Clinic of Surgery, St George University Hospital in Plovdiv over a 6-month period from September 2020 to February 2021. RESULTS: Seventeen of the patients were men and nine - women. Twenty-four of all patients underwent thoracentesis and two of them had a video-assisted thoracoscopy. The mean age of the studied patients with pneumothorax and COVID-19 was 66.77±12.61 years, which shows that it is the patients of advanced age with concomitant diseases that are at a higher risk of serious complications and adverse outcome. Of the hospitalized 1245 patients with COVID-19, 385 (30.92%) passed away. Of all hospitalized patients with SARS-CoV-2, 26 (2.08%) developed pneumothorax. Sixteen of them (62%) passed away. The possibility of a lethal outcome for intubated patients increased more than twice. CONCLUSIONS: The pneumothorax as a complication of COVID-19 carries high mortality and severely worsens the prognosis for these patients.

Bilateral pheochromocytoma/intra-adrenal paraganglioma in von Hippel-Lindau patient causing acute myocardial infarction.

A 26-year-old male presented to the emergency department complaining of obstipation, severe headache and abdominal pain. An autopsy revealed bilateral pheochromocytoma and acute myocardial infarction. The tumor cells showed positive immunoreactivity of both chromogranin A and synaptophysin and were negative for adrenocortical markers such as SF-1, c17, scc, 3-HSD as well as SDHB, suggesting a germline mutation of the gene SDHB or SDHD. Molecular genetic analyses did not show a mutation in these two genes, but a mutation in the VHL gene, in exon 3: VHL c.499C>T. This is a missense mutation and causes an amino acid change (Arg167Trp).

Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study.

OBJECTIVE: We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia. METHODS: A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists. RESULTS: Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%). CONCLUSION: ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.

Acute perforated diverticulitis of the colon as a rare cause for development of abdominal compartment syndrome.

AIM: The aim of the present retrospective study was to assess the surgical approaches to acute perforated diverticulitis of the colon causing peritonitis and in some cases complicated with abdominal compartment syndrome (ACS). PATIENTS AND METHODS: A total of eight patients (6 males and 2 females) have been operated on for 5 years for perforated diverticulum of the colon. The males had a mean age of 72 +/- 2.6 years and the females--69 +/- 3.1 years. Case history records of the patients were studied retrospectively to evaluate the effectiveness of different surgical approaches used in patients with such disorders. The females had perforation of cecal diverticulum, five of the males had perforated diverticulum of the sigmoid colon and one had perforation of diverticulum of the descending colon. The diagnosis in all patients was made intraoperatively and only in two cases was it assumed prior to operation. In the female patient with cecal pathology right-sided hemicolectomy with primary anastomosis was performed. In the other six patients Hartmann's procedure was applied with a subsequent second-stage intervention to restore the intestinal continuity. RESULTS: Total feculent peritonitis was found in four of the patients with perforated diverticulum of the sigmoid colon, with signs of multiorgan failure, intra-abdominal hypertension (IAH >25 cm H2O level) and developed ACS. Despite the severity of the condition there was no lethal outcome. Two patients developed incisional hernia on the anterior abdominal wall. CONCLUSION: Based on the retrospective clinical analysis the authors conclude that primary hemicolectomy with one-stage anastomosis is the best procedure in patients in good condition and early stage on Hinchey classification. Total feculent peritonitis, associated with stage IV on Hinchey classification and signs of ACS requires Hartmann's procedure, following the principles of damage control surgery with obligatory use of temporary abdominal closure technique to control the syndrome and prevent a secondary one in the postoperative period. The indirect intravesical method of verification of IAH and ACS (the golden standard) is sufficiently precise for the clinical practice.

Safety and efficacy of modified radical lymph nodes dissection in patients with papillary thyroid cancer and clinically evident lymph nodes metastasis.

INTRODUCTION: Papillary cancer of the thyroid gland is well known as a lymphotropic type of cancer. In more than 50 percent of all cases it metastasizes first and mainly in regional lymph nodes. The extent of surgical intervention remains a subject of controversy and discussions. AIM: The aim of our retrospective study was to evaluate efficacy and safety of modified radical lymph node dissection (MRND) in patients with papillary thyroid cancer (PTC). PATIENTS AND METHODS: We performed a retrospective analysis of survival and quality of life of 19 patients who underwent surgery at the Department of General Surgery. All patients had papillary thyroid cancer and regional lymph nodes metastases. The results were compared to literature data on surgical interventions differing in extent and specifics. RESULTS: Our analysis and its parallel with literature data revealed better survival rates and quality of life in patients who had undergone total thyroidectomy (TT) with modified radical lymph nodes dissection in comparison with those ones who had undergone total thyroidectomy with berry picking (BP). CONCLUSIONS: Modified radical lymph nodes dissection is an effective and comparatively safe procedure for the treatment of patients with papillary thyroid cancer and regional lymph nodes metastases. If adequately performed it ensures better quality of life, longer survival and improves further control on distant metastases.

Interleukin-10-1082 promoter polymorphism in association with cytokine production and sepsis susceptibility.

OBJECTIVE: To investigate the -1082 (A/G) polymorphism in the promoter of the IL-10 gene in terms of IL-10 production from stimulated peripheral blood mononuclear cells (PBMC) and to evaluate the relationship of this polymorphism with susceptibility to severe sepsis and the outcome of the disease. DESIGN: Case-control study. SETTING: Research laboratory of Molecular Biology and Immunology and University Hospital ICU, Faculty of Medicine, Trakia University. PATIENTS: A total of 53 healthy volunteers and 33 patients in ICU meeting the criteria for severe sepsis were included. MEASUREMENTS AND RESULTS: The amplification refractory mutation system PCR was used for IL-10-1082 polymorphism detection. Isolated PBMC were stimulated with either C3-binding glycoprotein (C3bgp), lipopolysaccharide (LPS), phytohemagglutinin (PHA),or pokeweed mitogen (PWM). IL-10 production was measured in culture supernatants. The AA genotype was associated with lower IL-10 production in LPS-, PHA- or PWM-stimulated healthy PBMC. Patients with severe sepsis had significant elevation of A allele, compared with healthy controls (74.2% vs 52.8%; p=0.0062). Carriage of at least one copy of IL-10-1082 G allele in sepsis patients and in healthy controls resulted in a statistically significant increase in IL-10 production from stimulated PBMC. Surviving sepsis patients had a significant decrease of IL-10-1082 allele G frequency, compared with controls (17% vs 47.2%; p=0.012). An association between increased IL-10 production and poor outcome from sepsis was observed. CONCLUSION: The A allele of the -1082 polymorphism in the interleukin-10 gene promoter is associated with sepsis susceptibility, whereas G allele is associated with higher stimulated interleukin-10 production and increased mortality in severe sepsis.

Enteral nutrition in sepsis patients.

Sepsis, with its associated complications, is a leading cause of death in intensive care units. It is a major public health problem world-wide. The altered metabolism, severe condition and specific organ failure in sepsis patients get entangled in a vicious circle. Their treatment should invariably include nutritional support. The present survey summarizes the sepsis-induced metabolic changes so that they can be adequately compensated by nutritional support using specialized enteral formulas. We argue the necessity of introducing new efficient formulas as part of the so called immunonutrition. The basic requirements these formulas should meet are: 1. to provide sufficient amount of protein and energy substrate that can preserve the muscle function; 2. to be a source of substances that stimulate and protect enterocytes with restriction of bacterial translocation; 3. to help keep the liver function normal; 4. by including various substances with immunomodulating features to prevent and compensate the disturbances in the immune response.

High interleukin 12 and low interleukin 10 production after in vitro stimulation detected in sepsis survivors.

OBJECTIVE: To evaluate viability of isolated peripheral blood mononuclear cells (PBMC) and production of cytokines in vitro after stimulation as prognostic factors for survival in sepsis patients. DESIGN: Prospective study of the biological response of PBMC in the onset of severe sepsis. SETTING: Research laboratory of molecular biology and immunology and university hospital ICU, Faculty of Medicine, Trakia University. PATIENTS: Twenty-three patients meeting the criteria for severe sepsis, and 14 control subjects. INTERVENTIONS: Isolated PBMC were stimulated in vitro with: C3-binding glycoprotein (C3bgp; 30 microg), lipopolysaccharide (30 microg), phytohemagglutinin (20 microg), pokeweed mitogen (30 microg), and dexamethasone (500 microg). MEASUREMENTS AND RESULTS: We measured the levels of interleukins (IL) 6, 10, and 12 in culture supernatants. Stimulation with C3bgp and phytohemagglutinin led to significantly lower PBMC secretion of IL-6 in nonsurvivors than in survivors and healthy donors. Stimulation with C3bgp, lipopolysaccharide, and pokeweed mitogen considerably reduced IL-12 production in nonsurvivors. Stimulation with lipopolysaccharide and pokeweed mitogen caused immune cells in nonsurvivors to produce higher levels of IL-10 than in survivors. Survival of PBMC reduced viability for nonsurvivors' PBMC, both spontaneously and as induced by lipopolysaccharide or pokeweed mitogen. CONCLUSIONS: The viability of PBMC at the onset of sepsis and enhanced production of IL-12 and diminished production of IL-10 after stimulation with all stimuli used may be a favorable prognostic factor in sepsis.

Experimental study of the morphological and electromyographic characteristics of the most frequent iatrogenic lesions of the recurrent laryngeal nerves in thyroid surgery.

INTRODUCTION: Iatrogenic lesions of the recurrent laryngeal nerves remain one of the most severe and frequent complications in thyroid surgery. According to Eisele (Laryngoscope 1996;106:443) their incidence varies between 1% and 12% depending on the size of surgery. AIM: The aim of the study was to examine experimentally the type of neural lesion and the efficiency of stimulation electromyography for immediate evaluation of the recurrent laryngeal nerve function in the most common surgical traumas. MATERIAL AND METHODS: Ten clinically healthy and parasite-free male dogs of mixed breed weighing from 11 to 18 kg were used in the experiment. The injured laryngeal nerves of the experimental animals were examined histologically using Sudan III staining for myelin and Bilshovsky staining for neurofibrils. The intraoperative electromyography was performed with Neurostim 100. RESULTS: The results show severe damage both of the myelin sheath and neurofibrils in most of the surgical traumas of the nerve fiber. The electromyography of the laryngeal musculature shows complete interruption of the conduction of the action potential in all types of experimental lesions. CONCLUSION: EMG intraoperative monitoring of the laryngeal nerves appears the most effective measure to avoid the complication.

Surgical treatment of bronchobiliary fistulas due to complicated echinococcosis of the liver: case report and literature review.

Echinococcosis still remains a widespread disease associated with the development of a number of complications. The present study presents three patients, successfully treated surgically of bronchobiliary fistulas--in two of the patients the fistulas were due to complicated echinococcosis of the liver, and in the third patient the fistula was a result of a hepatic abscess which developed in a residual cavity after echinococcectomy. The patients were discharged from hospital in good health. The authors consider thoracophrenotomy to be the method of choice in the surgical treatment of patients with bronchobiliary fistulas; it allows performance of echinococcectomy and elimination of the bronchobiliary fistula. The results are discussed in relation to relevant data in literature.

Clinical and bacteriological results from the administration of Cefepime (Maxipime) in patients with severe sepsis.

BACKGROUND: The aim of the present study was to investigate the clinical and bacteriological efficacy of Cefepime administered to critically ill sepsis patients, as well as possible adverse reactions and interactions. MATERIAL/METHODS: 30 patients with severe sepsis of different origin were treated with Cefepime a dosage of 2.0 g bid. Of these patients, 26 survived (86.67%). The clinical and bacteriological effects of antibiotic administration were recorded at the end of treatment. RESULTS: The treatment outcomes in terms of clinical results were as follows: 17 patients cured (56.67%), 7 improved (23.33%), 2 with unsatisfactory outcome (6.67%), and 4 failures (13.33%). Cefepime treatment resulted in a reduction of the APACHE II score from ca. 20 at the beginning to 9.44 at the end, while the SOFA score fell from 7 to 2.62. This indicates improved clinical status and reversal of multiple organ failure. The bacteriological results were as follows: pathogen eradication in 17 cases (56.67%), pathogen persistence in 8 cases (26.67%), and superinfection in 5 cases (16.66%). Out of 80 total hemocultures, 63 proved to be sterile. In two cases in vitro Enterococcus faecium was isolated with antibiotic resistance. Of 81 total cultures of infectious foci, 10 showed resistance: 4 Pseudomonas aeruginosa, 4 Acinetobacter baumannii, and 2 Enterococcus faecalis. No side effects of Cefepime administration were recorded. CONCLUSIONS: Cefepime administration resulted in low mortality, clinical improvement, minimal resistance, and lack of side effects. Cefepime is an effective drug of first choice for critically ill sepsis patients