[Anesthetics and intensive therapeutic aspects of liver transplantation]. / A májátültetés aneszteziológiai-intenzív terápiás vonatkozásai.

One of the most prominent results of our age is organ transplantation, the single treatment option for patients with end-stage organ failure. The success of transplants depends on the donor care, the patient preoperative preassessment, the perioperative care of organ transplantation and aftercare. Successful transplantation therefore requires a prominent level of continuous collaboration between the surgeon, anaesthesiologist, radiologist, internal medicine and hepatologist, laboratory physician and almost all their associates. The complex interdisciplinary approach based on the research results can be used to improve the patient's condition through pharmacotherapy, physiotherapy and psychotherapy during the time spent on waiting lists. The emergence of more active, targeted therapeutic options in perioperative graft resuscitation may help the currently inferior quality transplantable grafts or resuscitation out (machine perfusion) or in the recipient, thereby increasing the number of liver transplants. Deeper knowledge of hemostatic processes, along with the development of surgical techniques, would increase the number of blood transplant free transplants, thus improving the long-term survival of grafts. The present study aims at presenting the anaesthesia and early intensive therapy aspects of liver transplantation from aptitude assessment, through anaesthesia to early intensive therapeutic treatment. Orv Hetil. 2018; 159(46): 1891-1897.

[Clinical application of the electric cardiometry based non-invasive ICON® hemodynamic monitor]. / Az ICON® elektromos kardiometrián alapuló nem invazív hemodinamikai monitor használata a klinikumban.

Establishment of a proper hemodynamic monitoring system in order to achieve optimal care among critically ill patients is fundamental. In contrast to invasive patient-checking systems, which were introduced decades ago and used in both adult and pediatric intensive care, the non-invasive methods have become more popular in recent years due to technical advancements in intensive care and patient monitoring. This increase in popularity can be attributed to the higher degree of safety and reduced complication rates as well as to its being more economical. Our summary focuses on the ICON® patient monitoring system. This newly engineered, non-invasive tool is based on electrical cardiometry, and uses hemodynamic parameters in both neonatal and pediatric care as well as in adults. The operating principle is simple: the conductivity of the blood in the aorta shows time-dependent changes. Prior to the opening of the aortic valve, the orientation of the red blood cells (RBCs) is random, and it is not until the contraction of the aorta that the RBCs and the opening of the aortic valve achieve a parallel position. The tool senses the conductivity between four placed electrodes, and measures the stroke volume (SV) and cardiac output (CO), before calculating other additional parameters (eg.: systemic vascular resistance) by tracing the variation of bioimpedance according to changes in the heart cycle. The most important advantages of ICON® are the measurements that are made available immediately as well as continuously, and the low complication rate that originates from its non-invasive operation. ICON® is a new, promising hemodynamic device in the tool belt of intensive care. Due to the nature of the device, it is possible to evaluate the status of the patient on a continuous basis, allowing for optimal care. To identify the more accurate clinical indications further measures will be necessary. Orv Hetil. 2018; 159(44): 1775-1781.

[Assistance medicine, a novel discipline of emergency medicine]. / A sürgosségi ellátás új területe: az assistance orvostan.

The number of international travels has been continuously increasing since World War II. Though the travelers' demand for safer ways of travelling appeared, only a handful of them sought pretravel advices. This is the reason why 50% of the travelers have to face some kind of medical problem during their journey. If they have travel insurance, the company's assistance team organizes, monitors and covers their abroad treatment. A doctor of the assistance team has to find her/his ways in various fields: not only a multidisciplinary medical knowledge is a must for a professional like this, but she/he needs to have a good grasp of the basic idea behind the insurance policy, too. Also, she/he should be familiar with the public health care systems of different countries and some legal knowledge is also needed. If the patients are unable to continue their trip, they must be repatriated. Making a decision about the repatriation's timing and modality requires interdisciplinary medical experience and the approach of a critical care/emergency doctor. Among further tasks for the assistance team's doctor one can find medical escort and on-spot medical visit for foreign patients. Both of these two aforementioned medical activities are highly different from - for example - a general practitioner's routine. That is the reason why an assistance doctor has to be familiar with the critical and emergency care. Organizing and monitoring medical treatment for a traveler abroad, providing medical escort, making decisions about repatriation and providing medical help for a foreign patient all fall within the competence of a new medical discipline, the assistance medicine. Creating a body of knowledge, collecting appropriate protocols and establishing postgraduate courses for assistance medicine diplomas are the tasks of the critical care and emergency medicine professionals.

[The novelties of adult advanced life support and post-resuscitation therapy]. / A felnott emelt szintu újraélesztés és a postresuscitatiós ellátás újdonságai.

The fourth element of chain-of-survival contains advanced life support and post-resuscitation treatment. Both treatment options influence the outcome of patients suffering cardiac arrest. Advanced life support includes all interventions that require special medical equipment and expertise. High-quality chest compressions and early defibrillation (if indicated) compose the main elements of advanced life support. Clarifying and treating the cause of cardiac arrest have also high priority, in which point-of-care ultrasound plays an important role. In addition, securing higher level of airway and capnography, securing intravenous or intraosseous line, and the parenteral administration of drugs - such as epinephrine or amiodarone - are the most important steps of advanced life support. If conventional therapy is unsuccessful, extracorporeal circulatory support can be used in special patient populations. The protection of vital organs that are sensitive to hypoxia (brain and heart) has a high priority after the return of spontaneous circulation beside the causative treatment of cardiac arrest. The most important parts of the supportive post-resuscitation treatment are: targeting normoxia, normocapnia, normotension, normoglycemia, and the application of target temperature management. Orv Hetil. 2023; 164(12): 454-462.

[Determining factors of survival in patients with severe coronavirus infection admitted to intensive care unit in the third and fourth waves of COVID-19 pandemic]. / A kórházi túlélést meghatározó tényezok a COVID­19-járvány 3. és 4. hulláma idején súlyos koronavírus-fertozéssel intenzív osztályra felvett betegekben.

INTRODUCTION: During COVID-19 pandemic, a high mortality rate (20-60%) of patients admitted to intensive care unit has been observed. Identification of risk factors can support the understanding of disease pathophysiology and the recognition of vulnerable patients, prognostication and selection of appropriate treatment. OBJECTIVE: Beyond characterisation of a local, critically ill COVID-19 population, analysis of the associations between demographic/clinical data and patient survival were investigated. METHOD: Retrospective, observational study has been performed by recording demographic, clinical data and outcome parameters on patients with severe respiratory insufficiency caused by COVID-19. RESULTS: 88 patients were enrolled. Median age was 65 years and 53% of patients were male, median BMI was 29 kg/m2. Noninvasive ventilation was used in 81%, endotracheal intubation in 45%, prone positioning in 59% of all cases. Vasopressor treatment was introduced in 44%, secondary bacterial infection was detected in 36% of all cases. Hospital survival rate was 41%. Risk factors for survival and the effect of evolving treatment protocols were analyzed with multivariable regression model. A better survival chance was associated to younger age, lower APACE II score and non-diabetic status. Effect of the treatment protocol was found to be significant (OR = 0.18 [95% CI: 0.04-0.76], p = 0.01976) after controlling for APACHE II, BMI, sex, two comorbidities and two pharmaceutical agents (tocilizumab, remdesivir). CONCLUSION: Survival rate was favourable if patients were younger, with lower APACHE II score and if non-diabetic. Low initial survival rate (15%) significantly improved (49%) in association with the protocol changes. We would like to facilitate Hungarian centres to publish their data and initiate a nationwide database to improve the management of severe COVID disease. Orv Hetil. 2023; 164(17): 651-658.

[The impact of the coronavirus pandemic on the mental health of critical care workers]. / A koronavírus-világjárvány hatása az intenzív ellátásban dolgozók mentális egészségére.

INTRODUCTION: The coronavirus pandemic has focused attention on the importance of critical care and highlighted the shortage of critical care specialists. Due to increasing workloads and high mortality rates, healthcare professionals were exposed to higher levels of physical and psychological stress during the pandemic than before. OBJECTIVE: Our study investigated the effects of the coronavirus outbreak on the emotional, mental and moral stress of intensive care professionals. METHOD: Our workgroup performed paper-based surveys among caregivers in the Department of Anaesthesiology and Intensive Therapy at Semmelweis University. The first survey was conducted at the start of the pandemic in 2020, the second survey was conducted after the third wave in 2021. We applied validated questionnaires (Professional Quality of Life, Demoralization Scale, Perceived Stress Scale, Impact of Event Scale, and Posttraumatic Growth Inventory), collected demographic data and information on lifestyle, recreation, dietary habits, and accepting psychological support. RESULTS: The number and demographic characteristics of the participants in the two studies are different, reflecting the changes in the workforce during the pandemic. Our results revealed no differences between the working and socio-demographic groups before the outbreak, however, one year later, nurses scored significantly higher on all negative psychological scales compared to other groups. Only a minority of the respondents had sought psychological support (9.5-12.7%), although more than a third of respondents reported the need for psychological support. Employees in new work positions showed significantly increased posttraumatic growth (2.91 ± 0.82 vs. 2.20 ± 1.06, p = 0.016). DISCUSSION: These findings demonstrate that nurses are the most strained workgroup during an uncertain and stressful period. The available mental support alone is not enough to help caregivers. CONCLUSION: Further steps are needed to improve the mental health of critical care workers. Orv Hetil. 2023; 164(42): 1646-1655.

[Challenge in modern intensive care: chronic critical illness - pathophysiology and therapeutic options]. / A modern intenzív terápia kihívása: az elhúzódó kritikus állapot kórélettani háttere és terápiás lehetoségei.

The recent developments in intensive care have resulted in improved survival rates of patients treated with acute organ deficiency. As a consequence, the rate of those who survive the acute phase and subsequently require protracted organ support due to persisting organ dysfunction has been growing. Several survivors display chronic health status deterioration leading to prolonged rehabilitation or nursing, and repeated hospitalizations. The condition developed following the survival of the acute phase and requiring long-lasting intensive care is frequently termed as chronic critical illness (CCI). Several definitions exist, most of these are based on the number of ventilator days, or days of stay at the intensive care unit. Nevertheless, in spite of the initially heterogenous etiology of the acute illness, the complications associated with CCI, as well as the pathophysiological processes underlying these, are relatively uniform. This causes CCI to be a unique clinical syndrome characterized by the development of secondary infections, myopathy, central and peripheral neuropathy, and typical alterations of the hormonal and immune system functions. The outcome is heavily influenced by the frailty and comorbidities of the patient, in addition to the severity of the acute illness. The treatment of CCI patients presents a complicated task requiring multidisciplinary view and individualized therapeutic measures. Since the aging of the population and the continuously improving success rates in overcoming acute conditions also facilitate the development of CCI, the systematic overview of the underlying pathophysiological processes is pivotal for the optimization of the medical, nursing, social and economical burden presented by this syndrome. Orv Hetil. 2023; 164(18): 702-712.

Does the dose of the culprit drug matter in hypersensitivity reactions? / Számít-e a gyógyszer dózisa a túlérzékenységi reakciókban?

Összefoglaló. Két fiatal nobetegnél a valproátról lamotriginre történo gyógyszerátállítás során a 3-4. héten influenzaszeru prodromalis tüneteket követoen toxikus epidermalis necrolysis (TEN), más néven Lyell-szindróma alakult ki. Mindkét beteg 5 napja kezdodött bor- és nyálkahártyatünetekkel, kiterjedt hámleválást okozó hámnekrózissal került felvételre a Debreceni Egyetem Borgyógyászati Klinikájának Égési Intenzív Osztályára. Multidiszciplináris szupportív terápia mellett nagy dózisú szteroid- és immunglobulin-terápiát alkalmaztunk. A 37 éves nobetegnél 3 hét után a kórkép fatális kimenetellel végzodött. A 19 éves nobeteg tünetei 4 hét intenzív terápia után szövodményekkel gyógyultak. A TEN ritka, gyógyszer által okozott, életet veszélyezteto, késoi hiperszenzitivitási reakció. Patogenezisében a gyógyszermolekula, a humán leukocytaantigén (HLA) I. osztályú molekula és a T-sejt-receptor kóros interakciója szerepel. Kezelésében a legfontosabb a kiváltó gyógyszer elhagyása, valamint az azonnal kezdett komplett szupportív terápia alkalmazása. A specifikus kezelést illetoen nincsenek egységes szakmai irányelvek. A veszélyes gyógyszerek titrált bevezetése csökkentheti a kialakuló hiperszenzitivitás súlyosságát, ezenfelül a beteg szoros követése és az adverz tünetek korai felismerése javíthatja a TEN kimenetelét. Orv Hetil. 2020; 161(46): 1959-1965. Summary. After switching from valproate to lamotrigine, on the 3rd-4th weeks, two young female patients developed flu-like prodromal symptoms, followed by the development of toxic epidermal necrolysis (TEN), also known as Lyell syndrome. Both patients were admitted to the Burn Intensive Care Unit of the Department of Dermatology, University of Debrecen with skin and mucosa symptoms; extensive epithelial death and detachment started 5 days earlier. In addition to multidisciplinary supportive treatment, high-dose corticosteroid and immunoglobulin therapy were administered. In the case of the 37-year-old female patient, the disease resulted in a fatal outcome. The 19-year-old patient healed with some sequelae. TEN is a rare, life-threatening delayed-type hypersensitivity reaction caused by drugs. Its pathogenesis involves an interaction between small-molecule drug, human leukocyte antigen class I molecule and T-cell receptor. The most important treatment is immediate withdrawal of potentially causative drugs and prompt application of supportive therapy. There is no standard guidance on specific treatment. Slow dose escalation of dangerous drugs can be beneficial in avoiding severe reactions, furthermore, close patient follow-up and early detection of the possible adverse reactions contribute to a more favourable outcome of TEN. Orv Hetil. 2020; 161(46): 1959-1965.

Challenges of intensive care and anesthesiology related to COVID-19 pandemic. Practical considerations / [Az aneszteziológiai és intenzív ellátás kihívásai a COVID­19-fertozéssel kapcsolatban. Gyakorlati ajánlás]

Due to the coronavirus epidemic, healthcare systems face growing challenges all around the world nowadays. These challenges are the most critical in the field of intensive treatment and anesthesiology. One of the most important prerequisites of effective critical care treatment is preserving the involved healthcare workers from the infection, by providing them with detailed practical advices on the preventive measures and treatment strategies. The aim of the present review is to summarize the most important related knowledge available from previous experiences. Orv Hetil. 2020; 161(17): 652­659.

Practical aspects of intensive care for critically ill COVID-19 patients requiring respiratory support / [Kritikus állapotú, légzéstámogatást igénylo COVID­19-fertozött beteg ellátásának gyakorlati szempontjai]

In December 2019, a novel outbreak of pneumonia was reported in Wuhan city, China. Initially, the zoonitic infection spread from human to human, causing a pandemic. This viral disease (COVID-19) can appear in a variety of forms, from asymptomatic through the spectrum of mild symptoms to severe respiratory failure, requiring intensive care. Caring for this latter group of patients puts a significant burden on health care. The purpose of this summary is to present the practical aspects of intensive care for patients requiring respiratory support and mechanical ventilation. Orv Hetil. 2020; 161(17): 678­684.