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Anestezjologia intensywna terapia [journal]
- Percutaneous cervical cordotomy in cancer pain. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Dec 19.
The aim of this study was to review all published articles in the literature in English regarding percutaneous cervical cordotomy in cancer pain. Percutaneous cordotomy may be used to relieve unilateral pain below the level of the neck arising from a variety of causes. It is particularly indicated for unilateral chest pain associated with malignant disease. We searched for reports on MEDLINE and EMBASE using the terms 'percutaneous cordotomy', 'fluoroscopy', 'computed tomography,' and 'cancer pain' up to and including 2013. Reports were also located through references of articles. This review leads us to conclude that percutaneous cervical cordotomy can be recommended even before considering the use of strong opioids.
- In memory of Professor Stanisław Nęcek. [Editorial]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):213-4.
- The polycompartment syndrome: a concise state-of-the-art review. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):433-50.
A compartment syndrome is defined as an increase in the compartmental pressure to such an extent that the viability of the tissues and organs within the compartment are threatened. The term describes a syndrome and not a disease, and as such there are many diseases and underlying pathophysiological processes that may lead to such a scenario. The aim of this review is to give a state-of-the-art overview on the current knowledge on different compartment syndromes and how they may interact. Suggested definitions are included. There are four major compartments in the human body: the head, chest, abdomen, and the extremities. Initially, the term multicompartment syndrome was suggested when more than one compartment was affected. But this led to confusion as the term multi- or multiple compartment syndromes is mostly used in relation to multiple limb trauma leading to compartment syndrome requiring fasciotomy. Only recently was the term 'polycompartment syndrome' coined to describe a condition where two or more anatomical compartments have elevated pressures. When more than one compartment is affected, an exponential detrimental effect on end-organ function to both immediate and distant organs can occur. Within each compartment, the disease leading towards a compartment syndrome can be primary or secondary. The compliance of each compartment is the key to determining the transmission of a given compartmental pressure from one compartment to another. The intra-abdominal pressure helps to explain the severe pathophysiological condition occurring in patients with cardiorenal, hepatopulmonary and hepatorenal syndromes. Initial treatment of a compartment syndrome should be focused on the primary compartment and is based on three principles: lowering of compartmental pressure, supporting organ perfusion, and optimisation and prevention of specific adverse events. Clinicians need to be aware of the existence of the polycompartment syndrome and the interactions of increased compartmental pressures between compartments.
- The role of abdominal compliance, the neglected parameter in critically ill patients - a consensus review of 16. Part 2: measurement techniques and management recommendations. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):406-32.
The recent definitions on intra-abdominal pressure (IAP), intra-abdominal volume (IAV) and abdominal compliance (Cab) are a step forward in understanding these important concepts. They help our understanding of the pathophysiology, aetiology, prognosis, and treatment of patients with low Cab. However, there is still a relatively poor understanding of the different methods used to measure IAP, IAV and Cab and how certain conditions may affect the results. This review will give a concise overview of the different methods to assess and estimate Cab; it will list important conditions that may affect baseline values and suggest some therapeutic options. Abdominal compliance (Cab), defined as a measure of the ease of abdominal expansion, is measured differently than IAP. The compliance of the abdominal wall is only a part of the total abdominal pressure-volume (PV) relationship. Measurement or estimation of Cab is difficult at the bedside and can only be done in a case of change (removal or addition) in IAV. The different measurement techniques will be discussed in relation to decreases (ascites drainage, haematoma evacuation, gastric suctioning) or increases in IAV (gastric insufflation, laparoscopy with CO₂ pneumoperitoneum, peritoneal dialysis). More specific techniques using the interactions between the thoracic and abdominal compartment during positive pressure ventilation will also be discussed (low flow PV loop, respiratory IAP variations, respiratory abdominal variation test, mean IAP and abdominal pressure variation), together with the concept of the polycompartment model. The relation between IAV and IAP is linear at low IAV and becomes curvilinear and exponential at higher volumes. Specific conditions in relation to increased (previous pregnancy or laparoscopy, gynoid fat distribution, ellipse-shaped internal abdominal perimeter) or decreased Cab (obesity, fluid overload, android fat distribution, sphere-shaped internal abdominal perimeter) will be discussed as well as their impact on baseline IAV, IAP, reshaping capacity and abdominal workspace volume. Finally, we suggest possible treatment options in situations of unadapted IAV according to existing Cab, which results in high IAP. A large overlap exists between the treatment of patients with abdominal hypertension and those with low Cab. The Cab plays a key role in understanding the deleterious effects of unadapted IAV on IAP and end-organ perfusion and function. If we can identify patients with low Cab, we can anticipate and select the most appropriate surgical treatment to avoid complications such as IAH or ACS.
- The role of abdominal compliance, the neglected parameter in critically ill patients - a consensus review of 16. Part 1: definitions and pathophysiology. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):392-405.
Over the last few decades, increasing attention has been paid to understanding the pathophysiology, aetiology, prognosis, and treatment of elevated intra-abdominal pressure (IAP) in trauma, surgical, and medical patients. However, there is presently a relatively poor understanding of intra-abdominal volume (IAV) and the relationship between IAV and IAP (i.e. abdominal compliance). Consensus definitions on Cab were discussed during the 5th World Congress on Abdominal Compartment Syndrome and a writing committee was formed to develop this article. During the writing process, a systematic and structured Medline and PubMed search was conducted to identify relevant studies relating to the topic. According to the recently updated consensus definitions of the World Society on Abdominal Compartment Syndrome (WSACS), abdominal compliance (Cab) is defined as a measure of the ease of abdominal expansion, which is determined by the elasticity of the abdominal wall and diaphragm. It should be expressed as the change in IAV per change in IAP (mL [mm Hg]⁻¹). Importantly, Cab is measured differently than IAP and the abdominal wall (and its compliance) is only a part of the total abdominal pressure-volume (PV) relationship. During an increase in IAV, different phases are encountered: the reshaping, stretching, and pressurisation phases. The first part of this review article starts with a comprehensive list of the different definitions related to IAP (at baseline, during respiratory variations, at maximal IAV), IAV (at baseline, additional volume, abdominal workspace, maximal and unadapted volume), and abdominal compliance and elastance (i.e. the relationship between IAV and IAP). An historical background on the pathophysiology related to IAP, IAV and Cab follows this. Measurement of Cab is difficult at the bedside and can only be done in a case of change (removal or addition) in IAV. The Cab is one of the most neglected parameters in critically ill patients, although it plays a key role in understanding the deleterious effects of unadapted IAV on IAP and end-organ perfusion. The definitions presented herein will help to understand the key mechanisms in relation to Cab and clinical conditions and should be used for future clinical and basic science research. Specific measurement methods, guidelines and recommendations for clinical management of patients with low Cab are published in a separate review.
- The use of bio-electrical impedance analysis (BIA) to guide fluid management, resuscitation and deresuscitation in critically ill patients: a bench-to-bedside review. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):381-91.
The impact of a positive fluid balance on morbidity and mortality has been well established. However, little is known about how to monitor fluid status and fluid overload. This narrative review summarises the recent literature and discusses the different parameters related to bio-electrical impedance analysis (BIA) and how they might be used to guide fluid management in critically ill patients. Definitions are listed for the different parameters that can be obtained with BIA; these include among others total body water (TBW), intracellular water (ICW), extracellular water (ECW), ECW/ICW ratio and volume excess (VE). BIA allows calculation of body composition and volumes by means of a current going through the body considered as a cylinder. Reproducible measurements can be obtained with tetrapolar electrodes with two current and two detection electrodes placed on hands and feet. Modern devices also apply multiple frequencies, further improving the accuracy and reproducibility of the results. Some pitfalls and conditions are discussed that need to be taken into account for correct BIA interpretation. Although BIA is a simple, noninvasive, rapid, portable, reproducible, and convenient method of measuring body composition and fluid distribution with fewer physical demands than other techniques, it is still unclear whether it is sufficiently accurate for clinical use in critically ill patients. However, the potential clinical applications are numerous. An overview regarding the use of BIA parameters in critically ill patients is given, based on the available literature. BIA seems a promising tool if performed correctly. It is non-invasive and relatively inexpensive and can be performed at bedside, and it does not expose to ionising radiation. Modern devices have very limited between-observer variations, but BIA parameters are population-specific and one must be aware of clinical situations that may interfere with the measurement such as visible oedema, nutritional status, or fluid and salt administration. BIA can help guide fluid management, resuscitation and de-resuscitation. The latter is especially important in patients not progressing spontaneously from the Ebb to the Flow phase of shock. More research is needed in critically ill patients before widespread use of BIA can be suggested in this patient population.
- Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):361-80.
Sepsis is associated with generalised endothelial injury and capillary leak and has traditionally been treated with large volume fluid resuscitation. Some patients with sepsis will accumulate bodily fluids. The aim of this study was to systematically review the association between a positive fluid balance/fluid overload and outcomes in critically ill adults, and to determine whether interventions aimed at reducing fluid balance may be linked with improved outcomes.We searched MEDLINE, PubMed, EMBASE, Web of Science, The Cochrane Database, clinical trials registries, and bibliographies of included articles. Two authors independently reviewed citations and selected studies examining the association between fluid balance and outcomes or where the intervention was any strategy or protocol that attempted to obtain a negative or neutral cumulative fluid balance after the third day of intensive care compared to usual care. The primary outcomes of interest were the incidence of IAH and mortality.Among all identified citations, one individual patient meta-analysis, 11 randomised controlled clinical trials, seven interventional studies, 24 observational studies, and four case series met the inclusion criteria. Altogether, 19,902 critically ill patients were studied. The cumulative fluid balance after one week of ICU stay was 4.4 L more positive in non-survivors compared to survivors. A restrictive fluid management strategy resulted in a less positive cumulative fluid balance of 5.6 L compared to controls after one week of ICU stay. A restrictive fluid management was associated with a lower mortality compared to patients treated with a more liberal fluid management strategy (24.7% vs 33.2%; OR, 0.42; 95% CI 0.32-0.55; P < 0.0001). Patients with intra-abdominal hypertension (IAH) had a more positive cumulative fluid balance of 3.4 L after one week of ICU stay. Interventions to decrease fluid balance resulted in a decrease in intra-abdominal pressure (IAP): an average total body fluid removal of 4.9 L resulted in a drop in IAP from 19.3 ± 9.1 mm Hg to 11.5 ± 3.9 mm Hg.A positive cumulative fluid balance is associated with IAH and worse outcomes. Interventions to limit the development of a positive cumulative fluid balance are associated with improved outcomes. In patients not transgressing spontaneously from the Ebb to Flow phases of shock, late conservative fluid management and late goal directed fluid removal (de-resuscitation) should be considered.
- Effects of intravenous solutions on acid-base equilibrium: from crystalloids to colloids and blood components. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):350-60.
Intravenous fluid administration is a medical intervention performed worldwide on a daily basis. Nevertheless, only a few physicians are aware of the characteristics of intravenous fluids and their possible effects on plasma acid-base equilibrium. According to Stewart's theory, pH is independently regulated by three variables: partial pressure of carbon dioxide, strong ion difference (SID), and total amount of weak acids (ATOT). When fluids are infused, plasma SID and ATOT tend toward the SID and ATOT of the administered fluid. Depending on their composition, fluids can therefore lower, increase, or leave pH unchanged. As a general rule, crystalloids having a SID greater than plasma bicarbonate concentration (HCO₃-) cause an increase in plasma pH (alkalosis), those having a SID lower than HCO₃- cause a decrease in plasma pH (acidosis), while crystalloids with a SID equal to HCO₃- leave pH unchanged, regardless of the extent of the dilution. Colloids and blood components are composed of a crystalloid solution as solvent, and the abovementioned rules partially hold true also for these fluids. The scenario is however complicated by the possible presence of weak anions (albumin, phosphates and gelatins) and their effect on plasma pH. The present manuscript summarises the characteristics of crystalloids, colloids, buffer solutions and blood components and reviews their effect on acid-base equilibrium. Understanding the composition of intravenous fluids, along with the application of simple physicochemical rules best described by Stewart's approach, are pivotal steps to fully elucidate and predict alterations of plasma acid-base equilibrium induced by fluid therapy.
- Why crystalloids will do the job in the operating room. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):342-9.
The current trend in anaesthesia is to choose crystalloid over colloid fluids for volume replacement in the operating room. Outcome-oriented studies and kinetic analyses have recently provided more insight into how crystalloid infusions should be managed. These fluids have a much better short-term effect on the plasma volume than previously believed. Their efficiency (i.e. the plasma volume expansion divided by the infused volume) is 50-80% as long as an infusion continues, while this fraction increases to 100% when the arterial pressure has dropped. Elimination is very slow during surgery, and amounts to only 10% of that recorded in conscious volunteers. Capillary refill further reduces the need for crystalloid fluid when bleeding occurs. These four factors limit the need for large volumes of crystalloid fluid during surgery. Adverse effects associated with crystalloid fluids mainly include prolonged gastrointestinal recovery time, which occurs when > 3 L has been infused. Clinicians who do not want to prolong the length of the hospital stay by 1-2 days due to such problems may use colloid fluid selectively, but calculations show that the therapeutic window for colloids is quite narrow. Inflammation is likely to decrease the fluid efficiency of colloid fluids, while its effect on crystalloids is unclear. However, some recent evidence suggests that inflammation accelerates the turnover of crystalloid fluid as well.
- Why hydroxyethyl starch solutions should NOT be banned from the operating room. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Nov-Dec; 46(5):336-41.
This review summarises the new insights into the physiology of perioperative fluid therapy and analyses recent studies of the safety of the use of HES solutions in the fluid management of critically ill patients. This analysis reveals a number of methodological issues in the three major studies that have initiated the recommendation of the European Medicine Agency to ban hydroxyethyl starches from clinical practice. It is concluded that, when used in the proper indication, and taking into account the recommended doses, hydroxyethyl starches continue to have a place in perioperative fluid management.