Anestezjologia intensywna terapia最新文献

Lipid solutions used in parenteral nutrition (PN) are generally well tolerated. Recent studies reporting their effects on the immune system indicate that various compositions can modulate the immune response, thus affecting the response to pathogens and autoaggressive diseases. In this review, we discuss the compositions of various commercially available lipid solutions and their effects on the immune response to various pathologies. We conclude that: 1. Soybean oil-based emulsions are immunosuppressive and should be used with caution in inflammatory conditions, and are contraindicated in sepsis. 2. Mixtures of medium chain triglycerides and soybean oil are better tolerated. 3. Olive oil-based mixtures are neutral and are especially recommended for burned patients, premature infants and for long term PN. 4. Fish oil-based emulsions are beneficial in inflammatory conditions and in patients after major abdominal surgery.

Background: Among many factors that may affect mortality among ITU patients, the time of admission has been reported to play some, but ill-defined role. In the retrospective study, we analysed the time of admission, severity of the underlying disease, clinical status on admission and mortality among adult patients treated in a single ITU over a six-year period.

Methods: We compared the mortality of patients who were admitted during daytime (7 a.m. to 6:59 p.m.) and at night (7 p.m. to 6:59 a.m.). We also compared those admitted on weekdays (Monday 7 p.m. to Friday 6:59 a.m.) to those admitted during weekends (Friday 7 p.m. to Monday 7 a.m.). The patients condition was assessed using the APACHE II scale. Brain dead organ donors and readmissions were excluded from the analysis.

Results: The retrospective study involved the data of 1789 patients. Mortality was higher in patients who were admitted during the night and during weekends, when compared to daytime and weekdays, respectively. Mortality was also higher in patients admitted directly from the operating theatre after emergency surgery, but only during nights and weekends. The following independent factors in ITU mortality have been identified: length of ITU stay (OR 1.015; % CI 1.005-1.024), admission from a hospital ward (OR 1.39; 95% CI 1.04-1.86) and APACHE II score (OR 1.177; 95% CI 1.156-1.198).

Conclusion: Time of admission has not been identified as a single independent factor of ITU mortality, but admissions at night and during weekends were associated with higher mortality, probably because of emergency conditions.

Sex steroids play an important role in neuroprotection following brain injury. Although their protective action has been found to be effective in many experimental animal models, their use in humans remains controversial. Many authors have shown that the frequency and extent of post-ischaemic damage is sex-dependent, and even low concentrations of estrogens are neuroprotective, but not therapeutic. The authors have summarized the current knowledge of neuroprotection by sex steroids in experimental and clinical settings. They conclude that direct extrapolation from animals to humans is not possible, and so far, widespread clinical use of sex steroids in humans is not justified.

Background: The social status of physicians has been traditionally high in Poland, over recent years, we have noticed increased patient expectations in relation to the newest technology and the highest possible competence. The patient s image of medical personnel may influence his or her opinion about the quality of the service and of the medical centre. At the same time, we have noticed signs of decreasing trust, and an increased number of legal claims against doctors. The purpose of this study was to compare the image of anaesthesiologists, as perceived by patients who underwent Caesarean section either with general or spinal anaesthesia.

Methods: Five hundred and thirteen parturients were asked to complete a questionnaire about their view of the attending anaesthesiologist, assessing the doctors attitude with 7-degree visual-analogue scale.

Results: Four hundred and twelve valid forms were returned. Women who received spinal anaesthesia rated their anaesthesiologist higher than those who had general anaesthesia. Among the most important factors that influenced their opinion were: competence, calmness, trustfulness, accurate and detailed information, patience and kindness. Feelings of intimacy and privacy were less important, but the length of the preoperative visit was found to be a relevant factor. Anaesthesiologists providing spinal anaesthesia were rated higher, probably because they were spending more time with awake patients than those who had chosen general anaesthesia. The latter may also have been in a hurry, because of co-existing emergencies.

Conclusion: We conclude that patients satisfaction depends mainly on the time spent with their doctors before anaesthesia and during the procedure. Regional anaesthesia may increase the patients trust and satisfaction, when compared with general anaesthesia.

Background: The costs of anaesthesia in Polish hospitals are usually calculated as a percentage of the cost of the surgical procedure, or as a percentage of the total cost of the operating theatre. These methods cannot be accurate, since they do not take into consideration, the specifics of anaesthesia. Therefore, a new method of calculation, based of the actual use of materials and manpower, has been introduced in our institution.

Methods: Anaesthesia procedures were divided into nine categories, according to risk of anaesthesia, type of surgery, type of anaesthesia, and working hours of the anaesthetic personnel. Each category was priced in points which expressed the actual value of the service provided, and the resulting totals were allocated to surgical specialties.

Results: The costs of anaesthesia calculated by the new method differed markedly from previous calculations. The number of anaesthetics between 2008 and 2010 increased by 20%, while the cumulative costs of anaesthesia rose by only 13%, when compared to the previous method of calculation. Changes in anaesthesia costs, in various surgical specialties, varied from -49% to +65%, and were not related to the number of procedures.

Conclusion: The new scoring system made it possible to calculate actual anaesthesia costs in various surgical specialties. It is logical and practical and merits recommendation.

Background: Pneumocystis jiroveci (old name Pneumocystis carini) can cause severe pneumonia in immune-compromised patients, most commonly those who are HIV infected.

Case report: A 68-yr-old man, who eight years earlier had undergone trauma related splenectomy, was admitted to ITU after a cardiac arrest due to septic shock caused by unknown pathogen. He had been treated for three weeks with various antibiotics without improvement. On the second day after resuscitation, high concentration of lgM anti-Pneumocystis jivecii antibodies was found, and high-dose trimetoprim therapy was started and continued for two weeks, Further treatment was complicated by ventilator-associated pneumonia (Acinetobacter baumannii); the patient eventually recovered without any neurological sequelae, and was transferred to a low-dependency area after 4 weeks in ITU.

Conclusion: We conclude that Pneumocystis jiroveci infection should be suspected as a cause of severe pneumonia in splenectomised patients.

Background: In the Netherlands, the employment as a "nurse anaesthetist" is comparable to that of a registered nurse anaesthetist in the Scandinavian countries and Poland. However, the Dutch healthcare system employs nurse anaesthetists both with and without nursing backgrounds. This study has investigated whether a nursing background influences the attitudes and perceptions of nurse anaesthetists in the Netherlands.

Methods: A survey was distributed to all nurse anaesthetists working in Dutch hospitals to discover differences in their perceptions of their work context, job satisfaction, and work climate, as well as health and turnover intention. The questionnaire also sought basic information on socio-demographic factors and psychosomatic symptoms. Descriptive statistics, factor analyses and independent T-tests were computed.

Results: Overall 923 of a total of 2,000 questionnaires were completed and analysed (response rate of 46%). Independent T-tests showed no significant differences between nurse anaesthetists with and those without nursing backgrounds in all the areas examined.

Conclusion: Dutch nurse anaesthetists with and without nursing backgrounds reported similar perceptions of and information about their work context, job satisfaction, work climate, psychosomatic symptoms, burnout, sickness absence, general health and turnover intention. Both academic tracks appeared to produce individuals who functioned similarly as professionals.

Background: Ventilator-associated pneumonia (VAP) occurs in approximately 10-20% of mechanically ventilated patients, and is associated with an extremely high mortality rate (up to 70%). The purpose of the study was to determine the susceptibility spectrum of Klebsiella, Pseudomonas and Acinetobacter strains isolated from VAP patients.

Methods: We analysed 81 strains of microorganisms isolated from bronchoalveolar lavages (BAL) of VAP patients. The minimal inhibitory concentrations (MIC) of antibiotics recommended for empirical therapy were determined using an automated VITEK 2 system, and for the MIC of doripenem - the Etest assay. Results were analysed following the guidelines of the Clinical and Laboratory Standards Institute.

Results: For infections caused by the group of bacteria under investigation, the most successful regimen was monotherapy with carbapenems (doripenem, meropenem and imipenem). Cephalosporins (cefepim and ceftazidim) were less effective in vitro. The worst results were obtained with the combination of piperacillin/tazobactam with aminoglycosides (amikacin or gentamicin) or fluoroquinolones (ciprofloxacin).

Conclusions: Antibiotic monotherapy proved to be more effective in VAP patients than combined therapy; the best results were achieved with carbapenems. Doripenem showed strong activity in vitro against P. aeruginosa and Klebsiella sp. and should be considered for empirical VAP therapy; however, carbapenems may be less effective against Acinetobacter baumannii. The wide range of bacteria, and their broad range of susceptibility to antibiotics, suggests the need for modification of current recommendations.

Background: Road traffic accidents resulting in multiple organ trauma are among the leading causes of mortality among people under 45 years of age. Those with pelvic injury are at special risk, because of difficult haemostasis and massive bleeding of mixed origin. Various methods of treatment have been used, including laparotomy, direct clamping and ligation of affected vessels, retroperitoneal packing, and external/internal pelvic stabilisation. In selected cases, angioembolisation of various vessels can be used

Case reports: A 24-year-old male patient was admitted after a road traffic accident, in which he suffered multiple injuries to the skull, abdomen and pelvis. An emergency laparotomy was performed, revealing ruptures of the spleen, mesentery, right ureter, and bladder, and a giant haematoma in the retroperitoneal space. The spleen was removed, and the traumatised organs temporarily repaired. The pelvis and femoral bones were stabilised externally. After surgery, the patient was transferred to the ITU; he was haemodynamically unstable due to coagulopathy and persistent bleeding from the superior gluteal artery. On the fourth day, angioembolisation of the latter was performed using three occluding coils that resulted in immediate control of the bleeding and haemodynamic stabilisation.

Discussion and conclusion: In selected cases of severe bleeding from a traumatic pelvic injury, angioembolisation can be used as a lifesaving technique, especially in patients with coagulopathy after ineffective surgical interventions.