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Anestezjologia intensywna terapia [journal]
- Swift recovery of severe acute hypoxemic respiratory failure under non-invasive ventilation. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Oct 27.
In the setting of severe acute respiratory distress syndrome (ARDS; PaO₂/FiO2 < 100), the cut-off point for switching from non-invasive ventilation to intubation combined to mechanical ventilation is poorly defined.The swift resolution over 10 h of a severe acute hypoxemic respiratory failure (P/F = 57) caused by aspiration following heroin overdose, using non-invasive ventilation (NIV)-high PEEP (15-20 cm H₂O)-low pressure support (8 cm H₂0) is reported. The success in treating non-invasively severe hypoxia was presumably linked to a highly restricted subset: healthy young patient, minimal alteration of consciousness, non-combativeness, absence of severe metabolic acidosis, quick resolution of supraventricular arrhythmia, one-to-one supervision by the intensivist in the critical care unit.Given the complications associated with tracheal intubation and mechanical ventilation on the one hand and with delayed intubation on the other hand, high PEEP-NIV may warrant study in a restricted set of patients closely monitored in a critical care environment.
- Role of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: adjuncts to damage control resuscitation to prevent intra-abdominal hypertension. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Oct 8.
Secondary Intra-abdominal hypertension : (IAH) and : Abdominal compartment syndrome (ACS) are closely related to fluid resuscitation. IAH causes major deterioration of the cardiac function by affecting preload, contractility and afterload. The aim of this review is to discuss the different interactions between IAH, ACS and resuscitation and to explore new hypothesis with regard to damage control resuscitation, permissive hypotension and global increased permeability syndrome. : METHODS: Review of the relevant literature via PubMed search. : RESULTS: Damage Control Resuscitation (DCR) is a concept that has recently been introduced in the critical care setting. DCR differs from current resuscitation approaches by attempting an earlier and more aggressive correction of coagulopathy as well as metabolic derangements like acidosis and hypothermia, often referred to as the deadly triad or the bloody vicious cycle. Permissive hypotension involves keeping the blood pressure low enough to avoid exacerbating uncontrolled hemorrhage while maintaining perfusion to vital end organs. The potential detrimental mechanisms of early, aggressive crystalloid resuscitation have been described. Limitation of fluid intake by using colloids, hypertonic saline (HTS) or hyperoncotic albumin solutions have been associated with favorable effects. HTS allows not only for rapid restoration of circulating intravascular volume with less administered fluid but also attenuates post-injury edema at the microcirculatory level and may improve microvascular perfusion. Capillary leak represents the maladaptive, often excessive, and undesirable loss of fluid and electrolytes with or without protein into the interstitium that generates edema. The global increased permeability syndrome (GIPS) has been articulated in patients with persistent systemic inflammation failing to curtail transcapillary albumin leakage and resulting in increasingly positive net fluid balances. GIPS may represent a third hit after the initial insult and the ischemia reperfusion injury. Novel markers like the capillary leak index, extravascular lung water and pulmonary permeability index may help the clinician in guiding appropriate fluid management. : CONCLUSIONS: Capillary leak is an inflammatory condition with diverse triggers that results from a common pathway that includes ischemia-reperfusion, toxic oxygen metabolite generation, cell wall and enzyme injury leading to a loss of capillary endothelial barrier function. : Fluid overload should be avoided in this setting. :
- Drug administration via enteral feeding tubes in intensive therapy - terra incognita? [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):307-11.
The use of enteral feeding tubes has become more frequent, both in hospital settings and in home care. The feeding tubes serve not only to deliver nutrients, but also as a route for medication provision. Nonetheless, the pharmaceutical, legal and technical implications of medication delivery via enteral feeding tubes are not widely understood by doctors and nurses. Not only is the type of medication relevant, but also the type of feeding tube. Crushing tablets may have detrimental effects for a patient and a staff member too. Administering a drug via enteral feeding tubes usually falls outside the terms of the licence (off-label), so burdening medical staff with the entire responsibility for potential adverse reactions.
- Cardiogenic shock - diagnostic and therapeutic options in the light of new scientific data. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):301-6.
Shock is a manifestation of circulatory failure related to an inadequate supply of oxygenated blood to the tissues. One type of shock is cardiogenic shock resulting from abnormalities of myocardial structure and function, impairment of mechanical function of the heart, or arrhythmia. Most commonly, cardiogenic shock is due to an acute myocardial infarction, particularly involving the anterior wall. However, establishing the diagnosis of cardiogenic shock and determining its aetiology is not always easy. Techniques of invasive haemodynamic monitoring, measurements of specific biomarkers, and noninvasive bedside echocardiography may be helpful. The effectiveness of shock management depends on the ability to institute appropriate therapy rapidly and to remove the underlying aetiologic factor(s). We present a state-of-the-art review of basic approaches used for the diagnosis and management of cardiogenic shock.
- Current treatment of convulsive status epilepticus - a therapeutic protocol and review. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):293-300.
The management of status epilepticus (SE) has changed in recent years. Substantial differences exist regarding the definition and time frame of a seizure, which has been operationally defined as lasting for 5 min. Not only have many new intravenous drugs, such as levetiracetam and lacosamide been introduced but other routes of administration, such as intranasal or buccal administration for midazolam, are also being developed. Optimal and successful therapy initiated at the appropriate moment, adequately tailored to the clinical state of the patient, determines the first step in the normalisation of vital functions and leads to the restoration of the physiological homeostatic mechanisms of the organism. The aim of this review is to present the current treatment options for the management of convulsive status epilepticus (CSE) that have been widely confirmed as the most effective in clinical trials and approved by the international neurology authorities as the actual therapeutic standards. We also intend to indicate distinct and unequivocal differentiation and therapeutic indications for each phase of CSE, including the precise doses of the related medications, to present practical guidelines for clinicians. The treatment of patients with CSE requires emergency physicians, neurologists and specialists in intensive care to work together to provide optimal care that should be initiated as soon as possible and conducted as a unified procedure to improve neurocritical care in patients who are transferred from the ambulance service, through the emergency department and finally to the neurology department or ICU. Appropriate treatment also involves avoiding mistakes associated with inadequate doses of medications, overdosing a patient or choosing an inappropriate medication.
- Subarachnoid haemorrhage imitating acute coronary syndrome as a cause of out-of-hospital cardiac arrest - case report. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):289-92.
Severe subarachnoid haemorrhage (SAH) is a common cause of cardiac arrest. The survival of patients with out-of-hospital cardiac arrest (OHCA) due to SAH is extremely poor. Electrocardiographic and echocardiographic changes associated with SAH may mimic changes caused by acute coronary syndromes (ACS) and thus lead to delayed treatment of the primary disease. Misdiagnosed SAH due to ACS mask can have an influence on patient outcomes.A 47-year-old man presented with a history of out-of-hospital cardiac arrest due to asystole. He had a medical history of hypertension, smoking, and a diffuse, severe headache for one week. The ECG showed atrial fibrillation, 0,2 mV ST-segment elevation in leads aVR and V1-V3 and 0.2 mV ST-segment depression in leads I, II, aVL and V4-V6. Echocardiography revealed left ventricular function impairment (ejection fraction < 20%). The CK-MB activity was 98 U L⁻¹ and the troponin I concentration was 0.59 μg L⁻¹. ACS was suspected. Coronarography did not reveal any changes in the coronary arteries. An urgent CT of the head was arranged and showed an extensive SAH.It appears that an urgent CT of the head is the most effective method for the early identification of SAH-induced OHCA, especially in patients with prodromal headache, no history of the symptoms of ACS and CA due to asystole/pulseless electrical activity (PEA). Out-of-hospital cardiac arrest (OHCA) predominantly develops due to acute coronary syndrome (ACS). Extra-cardiac causes, e.g., subarachnoid haemorrhage (SAH), are less common. The purpose of the present case report was to describe a patient with OHCA due to subarachnoid haemorrhage imitating acute coronary syndrome.
- The effect of bispectral index monitoring on anaesthetic requirements in target-controlled infusion for lumbar microdiscectomy. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):284-8.
Target-controlled infusion (TCI) is used to maintain the desired concentration of a hypnotic drug in the plasma and brain. However, pharmacodynamic variability can cause problems with maintaining the adequate level of anaesthesia. The bispectral index (BIS) is one of only a few parameters that allow an assessment of the depth of anaesthesia. In the present study, we attempted to determine the optimal dosages of drugs used for total intravenous anaesthesia with TCI based on BIS-guided monitoring of depth of anaesthesia.The study was conducted in 60 ASA I patients undergoing elective surgery due to lumbar discopathy. The participants were divided into two groups of 30 individuals. The patients were premedicated with 15 mg oral midazolam. Group I was the control group; group II received BIS monitoring. Anaesthesia was induced with TCI propofol (4 mg mL⁻¹), fentanyl (2 mg kg⁻¹) and vecuronium (0.12 mg kg⁻¹) and maintained with TCI propofol, continuous infusion of vecuronium (0.03 mg kg⁻¹ h⁻¹) and fractionated doses of fentanyl. ECG, HR, MAP, SaO₂, ETCO₂, and the degree of neuromuscular blockade were monitored, specifically at the following time points: T₁ - before induction, T₂ - after induction, T₃ - after intubation, T₄ - after positioning of the patient, T₅-T₁₃ - every 5 min during surgery, T₁₄ - on completion of surgery, T₁₅ - before extubation, T₁₆ - after extubation.The study groups were comparable in terms of age, body weight, duration of anaesthesia and recovery time. The haemodynamic parameters, such as HR and MAP, did not differ significantly between the groups. In both groups, changes in the mean MAP values were observed between T₁ and T₂, T₂ and T₃, T₃ and T₄ as well as T₁₄and T₁₅. The total dose of fentanyl and the doses of propofol were lower in the group that received BIS monitoring.BIS monitoring reduces the doses of opioids and hypnotics used during total intravenous anaesthesia by TCI.
- The prevalence of infections and colonisation with Klebsiella pneumoniae strains isolated in ICU patients. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):280-3.
Klebsiella spp. are among the bacteria most commonly isolated from patients with infections in ICUs. The source of these infections may be the microflora of the patient or the hospital environment. Increasingly, Klebsiella strains are also being isolated from epidemic outbreaks. This situation is largely the result of widespread, irrational antibiotic use, the virulence of the bacterial strains and their ability to survive in the hospital environment. The purpose of this dissertation was to estimate the prevalence of Klebsiella pneumoniae strains isolated from patients hospitalised in a single ICU.Seventy-eight isolates of K. pneumoniae were studied. The identification and the susceptibility to selected antibiotics were tested by an automated system, VITEK2 Compact. For the analysed strains, the production of different beta-lactamases was noted.Production of ESBL was detected in 64.1% of the K. pneumoniae strains isolated from infections and 74.4% from rectal swabs. Most of the strains were susceptible to imipenem (97.7%) and meropenem (96.1%). Sixty-nine (57.0%) of the analysed strains were identified as multidrug resistant.Most of the analysed Klebsiella pneumoniae strains produced ESBL-beta-lactamases. The frequency of colonisation and infection with multidrug resistant strains of K. pneumoniae in patients hospitalised in the ICU is very high.
- Assessment of the depth of anaesthesia during inhalational and intravenous induction of general anaesthesia. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):274-9.
Tracheal intubation is one of the strongest stimuli during general anaesthesia and may result in an insufficient depth of anaesthesia. The aim of the study was to compare the clinical evaluation of the depth of anaesthesia with an evaluation using entropy during inhalational and intravenous induction of general anaesthesia.This study involved 60 patients undergoing elective surgery under general anaesthesia. Patients were divided into two groups, group E (etomidate induction) and group S (sevoflurane induction). The systolic arterial pressure (SAP), heart rate (HR), response entropy (RE), and state entropy (SE) were determined at the following seven measurement points: before anaesthesia induction, at the loss of consciousness (LOC) point, before tracheal intubation, immediately after intubation, and 2 min., 4 min. and 6 min. after tracheal intubation. An increase in HR and/or SAP of more than 20% and/or the occurrence of lacrimation and/or perspiration in response to tracheal intubation was considered a marker of inadequate anaesthesia in the clinical evaluation. The depth of anaesthesia was considered insufficient according to entropy monitoring if the RE and SE were above 60.In clinical evaluation, insufficient anaesthesia in response to tracheal intubation was observed in all the patients in group E and in more than half of the patients in group S. At the same time, the majority of patients in both groups had entropy values that did not exceed the recommended value as an appropriate level of anaesthesia.We found a discrepancy in the evaluation of the depth of anaesthesia based on clinical criteria compared with evaluations based on entropy values during both intravenous and inhalational induction of general anaesthesia.
- Serum procalcitonin is a sensitive marker for septic shock and mortality in secondary peritonitis. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):262-73.
Serum procalcitonin (PCT) is considered to be a sensitive marker for the early recognition of severe infection. The aim of this study was to review the diagnostic accuracy of serum procalcitonin levels to predict the risk of septic shock and mortality in patients with secondary peritonitis.We carried out a retrospective review of patients (November 2010 to November 2012) admitted to the surgical intensive care unit (ICU) with secondary peritonitis classified into localised peritonitis (LP) or diffuse peritonitis (DP) groups. Organ dysfunction was assessed with the SOFA score. Demographic data was collected as well as results for neutrophil count, C- reactive protein, blood lactate, and PCT levels. The primary end-point was ICU mortality.From a total of 222 patients, 123 were allocated to the LP group and 99 to the DP group. Severe sepsis was observed in 41.9% of all patients in the DP group. The PCT levels increased significantly in the DP group, with the development of septic shock in 29 patients. Higher PCT levels were associated with an increased risk for septic shock with a cut-off value of 15.3 ng mL⁻¹ and an increased risk for mortality with a cut-off value 19.6 ng mL⁻¹. A total of 59.1% of those who developed septic shock died.An increase in PCT levels is an indirect sign of diffuse secondary peritonitis and this is associated with an increased risk of septic shock. Increased PCT level on admission is associated with an increased risk of mortality in this category of patients.