A patient with pulmonary hypertension waiting for donor lungs during the pandemic: 194 days on extracorporeal life support including 143 days on pulmonary artery to left atrium shunt.

Patients with pulmonary hypertension and end-stage lung disease are fraught with high mortality while on a waiting list for lung transplant. With sometimes rapid deterioration they may require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as an immediate life-saving technique, which is a time-limited solution. The technique of pulmonary artery to left atrium (PA-LA) shunt fitted with an oxygenator enables bridging the patient to transplant for a longer time period. This low-resistance paracorporeal pumpless lung assist device allows for de-adaptation of the right ventricle back to lower afterload before the lung transplantation is carried out. The PA-LA shunt with an oxygenator also conveys a risk of multiple complications with reported median of 10-26 days until transplant. We report a case of pulmonary capillary hemangiomatosis in a 35-year-old female who had to wait for donor lungs during the pandemic of SARS-CoV-2 for 143 days on PA-LA shunt with oxygenator following 51 days on VA-ECMO. The extremely long course associated with multiple complications including three cerebral embolisms, episodes of sepsis and ingrowth of the return cannula into the left ventricular wall gives insight into the limits of this bridging technique.

COVID-19 severe pneumonia: Prospective multicentre study on demands on intensive care capacities.

OBJECTIVES: The aim of the study was to obtain data on demands on the intensive care capacities to treat COVID-19 patients, and to identify predictors for in-hospital mortality. METHODS: The prospective observational multicentre study carried out from 1 March till 30 June 2020 included adult patients with confirmed SARS-CoV-2 infection with respiratory failure requiring ventilatory support or high-flow nasal oxygen therapy (HFNO). RESULTS: Seventy-four patients, 46 males and 28 females, median age 67.5 (Q1-Q3: 56-75) years, were included. Sixty-four patients (86.5%) had comorbidity. Sixty-six patients (89.2%) were mechanically ventilated, four of them received extracorporeal membrane oxygenation therapy. Eight patients (10.8%) were treated with non-invasive ventilation and HFNO only. The median of intensive care unit (ICU) stay was 22.5 days. Eighteen patients (24.3%) needed continuous renal replacement therapy. Thirty patients (40.5%) died. Age and acute kidney injury were identified as independent predictors of in-hospital death, and chronic kidney disease showed trend towards statistical significance for poor outcome. CONCLUSIONS: Sufficient number of intensive care beds, organ support equipment and well-trained staff is a decisive factor in managing the COVID-19 epidemic. The study focused on the needs of intensive care in the COVID-19 patients. Advanced age and acute kidney injury were identified as independent predictors for in-hospital mortality. When compared to clinical course and ICU management of patients with severe community-acquired pneumonia caused by other pathogens, we observed prolonged need for ventilatory support, high rate of progression to acute respiratory distress syndrome and significant mortality in studied population.

Extracorporeal membrane oxygenation to support repeated whole-lung lavage in a patient with pulmonary alveolar proteinosis in life threatening dyspnoe--a case report.

BACKGROUD: Pulmonary alveolar proteinosis is a rare disorder that is characterized by a large accumulation of lipoproteinaceous material within the alveoli. This causes respiratory failure due to a restriction of gas exchange and changes in the ventilation/perfusion ratio. Clinical symptoms are variable and depend on the severity of damage of the lung parenchyma. Treatment method is whole-lung lavage, where the accumulated lipoproteinaceous material is removed using large quantities of saline. CASE PRESENTATION: This case report describes a 45 year old patient with advanced pulmonary alveolar proteinosis. Due to the presence of severe global respiratory insufficiency, this patient could not undergo the classic whole-lung lavage using a double-lumen tube and selective lung ventilation. The whole-lung lavage was performed with the support of veno-venous extracorporeal membrane oxygenation. A total of 27 l of warm saline was used. CONCLUSION: According to the current published literature, whole-lung lavage with extra-corporeal membrane oxygenation support is a very rare treatment method. Even when taking into account all of the risks associated with whole-lung lavage and v-v extracorporeal membrane oxygenation support, we found that this technique is very effective and, without a doubt, it saved the life of our patient.

[Bloodstain pattern analysis on examples from practice: Are calculations with application parabolic trajectory usable?]. / Analýza krevních stríkancu na príkladech z praxe: Jsou výpocty po aplikaci parabolické trajektorie vyuzitelné?

The bloodstain pattern analysis (BPA) is useful in the forensic medicine. In Czechoslovakian criminology is this method not commonly used. The objective of this work is to calculate the impact length, height and distance splashing of blood drops. The results are compared with the real values for specific cases. It is also compared to calculate the angle of incidence of blood drops, using sinα with a form using tgα. For this purposes we used two different character cases from practice with well-preserved condition and readable blood stains. Selected blood stains were documented in order to calculate the angle of incidence of blood drops and to calculateorigin splashes. For this drop of blood, the distance of impact of the drops of blood (x), the height of the sprayed blood drops (y) and the length of the flight path the drop of blood (l). The obtained data was retrospectively analysed for the two models. The first straight line is represented by the triangle (M1) and the other is the parabolic model (M2). The formulae were derived using the Euler substitution. The results show that the angle of incidence of the drop of blood can be calculated as sinα and the tgα. When applying, the triangle is appropriate to consider the application and sinα parabolic requires the calculation of the angle of incidence drops of blood tgα. Parabola is useful for the BPA. In Czechoslovakian should be providing workplace training seminars BPA primarily intended for forensic investigators.We recommend the use of this method during investigations, verification of acts in forensic practice.

The use of trigonometry in bloodstain analysis.

Bloodstain pattern analysis (BPA) is a valid forensic method which belongs to the category of biological methods using trigonomic models. Despite its development through the years, the method has been re-formulated a standard one and globally used, recognized in standard sheets. This method permits exact analysis of the dynamic and characteristic properties of bloodstains after impact on surfaces such as floors, walls, and ceilings, various exterior and interior items, and clothes. It is also possible to determine the characteristics of blood from the outer part of the body. According to the presence of blood and its quantity, it is also possible to use this method for verification of reconstruction of criminal acts, while being tested for its validity with primary conditions of preserved and readable traces of blood. Even though this method is not considered as the major one or the only one information obtained in this way can be used for judicial. In our research, we tested the validity of this method in an experimental model using firearms. We compared measurements of the lengths of trajectory of impact and the height of the blood sprayed upwards from a distance of 1, 3, 5 and 10 meters. The experiment was based on two main presumptions. The first was the knowledge of the value of the distance and the angle of impact of the bloodstain, the second, the ability of the blood to reach a certain height and the angle of its impact. In accordance with trigonometric formulas, both the impact of the selected distance of drops of blood, and the height of the selected bloodstain could be determined without any verification of the flight trajectory and the distance of bloodstains. The results indicate that the method for these requirements differs from the real values, while increasing the measurements with the indicated spot of the shot. Aside from the unique values which were calculated, other results of the impact of the distance of drops of bloodstain were considered of lower value, and the values concerning the height of the bloods stains after the shot higher than real values. In spite of the lack of total accuracy, we recommend using this method widely and more often for investigation and verification of individual acts in criminal and forensic practice.

Surgery in drug use-associated infective endocarditis: long-term survival is negatively affected by recurrence.

OBJECTIVES: The prevalence of infectious endocarditis (IE) in intravenous drug users (IDUs) is increasing, and the number of patients who need surgery is also rising. Relatively little is known about the short-term and long-term outcomes of these operations. METHODS: This study is a retrospective analysis of our institutional results, focussing on risk factors for perioperative death, major adverse events and long-term survival. A total of 50 of the 66 (75.75%) patients had postoperative follow-up, and the mean follow-up time was 53.9 ± 9.66 months. Patients were divided into 2 groups depending on whether they were having their first operation or were being reoperated for recurrent IE. RESULTS: From March 2006 to December 2015, a total of 158 patients underwent surgery for IE; 72 (45.6%) of them were identified as active IDUs. The operative mortality in IDUs was 8.33% (6 patients), with no significant difference between the 2 groups (P = 0.6569). Survival rates at 1 year, at 3 years and at the end of follow-up were 92%, 72% and 64%, respectively. There was significantly worse survival of patients with recurrent IE (log-rank test, P = 0.03). CONCLUSIONS: Although the short-term results of operation for IE in IDUs are good, long-term outcomes are not satisfactory. The survival of patients with recurrence of IE caused by return to intravenous drug use is significantly worse.

Postoperative Outcome of High-Risk Octogenarians Undergoing Cardiac Surgery: A Multicenter Observational Retrospective Study.

PURPOSE: Cardiac surgery in octogenarians with severely deteriorated functional status is increasingly common, but outcome data are still limited. The aim of this study was to compare postoperative outcome, survival, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgery. METHODS: In all, 285 Czech octogenarians who underwent any cardiac surgical procedure between January 2011 and December 2012 were included in the study. Five out of all twelve national adult cardiac surgical centers participated in the study, representing almost half of all octogenarians operated in our country in that period. Patients' perioperative data were analyzed retrospectively. Follow-up was performed by interviewing patients by telephone. RESULTS: There was higher 30-day mortality (20% vs. 6.4% vs. 5.2%, respectively, p <0.001), lower 2-year survival (60% vs. 84.0% vs. 85.4%, respectively, p <0.05), and lower Karnofsky score (44.4 vs. 70.1 vs. 70.6, respectively, p <0.001) in high-risk group compared with medium- and low-risk groups, respectively. Greater improvement in New York Heart Association (NYHA) status was noted in high- and medium-risk groups compared with low-risk group (51% vs. 45% vs. 24%, respectively, p <0.05). CONCLUSION: High perioperative mortality, poor 2-year survival, and low postoperative quality of life have been observed in high-risk octogenarians undergoing cardiac surgery.

Direct thrombolysis of multiple thrombi in both right and left heart atrium in a patient on extracorporeal membrane oxygenation support following urgent double-lung transplantation: a case report.

BACKGROUND: Lung transplantation is considered an established treatment for patients with end-stage chronic respiratory failure. Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at high risk of death. Extracorporeal membrane oxygenation (ECMO) has been proposed as an alternative bridging strategy to mechanical ventilation. The shear stress created by the mechanical pumps causes changes in the hematological system in almost all patients treated with ECMO. An antithrombotic strategy to mitigate ECMO bleeding and thrombotic complications is necessary. The use of thrombolytic therapy is recommended for patients with acute symptomatic embolism with associated hypotension or shock. In this setting, the hemodynamic benefits of thrombolytic treatment far outweigh its bleeding risk. CASE PRESENTATION: This case report describes a 32-year-old woman suffering from lymphangioleiomyomatosis, who underwent urgent double-lung transplantation. This patient was maintained on ECMO preoperatively, perioperatively, and postoperatively due to life-threatening hypoxemia caused by the progression of her pulmonary tissue damage. Multiple thrombi developed in the early postoperative period, in both right and left heart atria. Direct thrombolysis was successfully performed on the first postoperative day. CONCLUSION: According to the current published literature, direct thrombolysis of thrombi in both right and left atria in a patient supported on ECMO following urgent double-lung transplantation is an extremely rare treatment method. Even when taking into account all of the risks associated with thrombolysis and arteriovenous ECMO support, we found that this technique is very effective and, without a doubt, it saved the life of our patient.