Anestezjologia intensywna terapia最新文献

Recently, numerous studies have been devoted to the issues of satisfaction of ITU patients and their families. Good relationships between the medical personnel and family members are essential for interpersonal communication built by both parties. The knowledge of rules ensuring proper relations with patients and their families is an important element of the medical staff education. To date, neither the medical curriculum nor additional training have focused on this issue. Good communication between the patients` families and physicians, thus the feeling of safety and satisfaction with the intensive care provided, should be based on controlled paternalism, provision of reliable information, confidence moulded, by mutual understanding and respect, elimination of impulsive reactions.

Background: Although broncho-alveolar lavage (BAL) culture and protected specimen brush (PSB) are regarded as the most effective methods in the diagnosis of VAP, a simple endotracheal aspiration (EA) is frequently performed during routine care, because of its simplicity and low cost. We compared the effectiveness of EA with BAL and PSB in VAP patients.

Methods: Sixty-one adult VAP patients, ventilated for longer than 48 h, were cultured with all three methods.

Results: Positive cultures were obtained from 63.9% of patients, with Acinetobacter baumannii being the most common pathogen. There was a high positive correlation between simple aspirates and BAL (k 0.817, CI 0.664-0.840, p <0.001) and aspirates and PSB (k 0.667, CI 0.483-0.871, p <0.001).

Conclusion: Because of the high sensitivity of bronchial aspirate culturing, compared to BAL and PSB, it can be used successfully in most cases.

Background: The influenza pandemic of 2009 was reported to be frequently associated with pulmonary complications, including ARDS. We report the case of a morbidly obese, 37-year-old, AH1N1-infected woman, who was admitted to a regional hospital because of rapidly progressing respiratory failure. She was treated successfully with high frequency oscillatory ventilation (HFOV) and low-flow extracorporeal CO2 removal.

Case report: The patient was admitted to a regional hospital because of severe viral infection, diabetes and hypertension that developed during pregnancy. On admission, she was deeply unconscious (GCS 5), hypotonic and anuric. Conventional ventilation, veno-venous haemofiltration, antibiotics and antiviral therapy (oseltamivir) did not improve the patient's condition, and she was transferred to a tertiary referral centre. Immediately before the transfer, she suffered two cardiac arrest episodes. They were successfully reversed. On admission, the patient was hypercapnic (PaCO2 150 mm Hg/20 kPa), acidotic (pH 6.92) and hyperkinetic (HR 120 min-1, CO 12.7 L min-1). Total lung compliance was 21 mL cm H2O-1, and SAP/DAP was 63/39 mm Hg). The PaO2/FIO2 index was 85. HFOV was instituted for 48 h, resulting in a marked improvement in gas exchange, however any manipulations caused immediate deterioration in the patient's condition. Extracorporeal CO2 removal was commenced and continued for 120 h, resulting in gradual improvement and eventual weaning from artificial ventilation after 17 days. Further treatment was complicated by septic shock due to Pseudomonas aeruginosa infection of the vagina, treated with piperacillin/tazobactam. The patient eventually recovered and returned to her regional hospital after 24 days.

Discussion: During the 2009 pandemic, a high number of pulmonary complications were observed all over the world. Viral infections are especially difficult to treat and the CESAR study indicated that the use of ECMO or extracorporeal CO2 removal devices may result in a lower mortality when compared with standard therapy. We conclude that the use of a simple CO2 removal device can be beneficial in complicated cases of AH1N1 influenza.

Background: Continuous veno-venous haemofiltration (CVVH) has been recommended for renal replacement therapy in acute renal failure (ARF). The aim of the study was to analyse the usefulness of CVVH in intensive therapy settings.

Methods: Sixteen adult patients, treated with CVVH because of ARF complicating multiple organ failure, were allocated to two groups: those who survived and those who did not. Serum lactate, creatinine, potassium, and C-reactive protein concentrations, together with WBC count and arterial blood gases, were assessed before the start of CVVH, and daily during the therapy. The severity of the patients' clinical state was rated according to the Sepsis-related Organ Failure Assessment scale (SOFA) at both the initiation and the termination of therapy.

Results: The demographic data did not differ between the groups. Mean serum creatinine (171.5 vs 282.9 mmol L-1, p<0.05), blood lactate (1.8 vs 3.5 mmol L-1, p<0.05), and potassium concentrations (3.9 mmol L-1 vs 4.5 mmol L-1, p<0.05) were significantly higher in those patients who died. Mean SOFA scores were similar in both groups before the start of treatment, but were increased significantly at the end of therapy in the patients who died (7.0 vs 15.0, p<0.05). The concentrations of CRP, and WBC counts were similar in both groups.

Conclusions: We concluded that CVVH can be instituted in cases of ARF, regardless of age or condition of patients. Early institution of CVVH was effective and resulted in normalization of renal function and biochemical parameters.

Background: Surgical procedures frequently require blood transfusion. Blood and its components are frequently ordered and cross-matched excessively, without proper analysis of the real needs. The purpose of this retrospective study was to analyse the actual intraoperative requirement vs the ordering of blood, and the transfusion practices of the University Hospital.

Methods: We analysed the records of all patients scheduled for surgery in July 2007, allocating them to four groups: high, medium, low and minimal risk of blood loss and transfusion. The following calculations were made: cross-match to transfusion RBC ratio (C/T); the number of patients transfused compared to those cross-matched (transfusion probability - %T); and the number of units transfused relative to the number of cross-matched patients (transfusion index - TI). The values justifying blood ordering were: C/T ratio <3.0, %T >30% and TI>0.5.

Results: In all four study groups the limit values were not reached. The C/T ratios were 6.61 (high risk group), 13.7 (medium risk group) and 35.5 (low and minimal risk groups). The overall C/T ratio was 9. The %T values were 18.8%, 8.69% and 2.94%, respectively. The TI values were 0.27, 0.42 and 0.15.

Conclusions: We conclude that preoperative blood ordering is far from being related to real needs, and suggest therefore, that hospital blood ordering policy should be reassessed.

Arthrogryposis is a rare congenital syndrome, characterised by multiple joint contractures. Children suffering from this disease often need surgical interventions to correct musculoskeletal abnormalities. Among problems which may be encountered are a difficult airway, myopathy, difficulties with peripheral iv placement, and the possibility of intraoperative hyperthermia. In three described cases, we used thiopentone and cis-atracurium to induce anaesthesia, which was then maintained with nitrous-oxide and fentanyl. In one case sevoflurane was also used. No problems with intubation or hyperthermia were encountered.

Background: Subcutaneous emphysema (SE) is rarely life-threatening, although it may create significant discomfort to patients. It may impede eye opening, movement of the limbs and sometimes causes stridor and respiratory distress. We describe two cases of SE, in which small incisions in the skin helped to relieve symptoms.

Case reports: Case 1. A 64-year-old male was admitted to ITU, having been intubated after blunt chest trauma during a traffic accident. Initial presentation included respiratory failure, massive SE of the face, neck and chest, and fractured ribs with bilateral pneumothorax and bilateral lung contusion. Ventilation with BiPAP with 15 cm H2O PEEP was commenced and a right chest drain was inserted. This resulted in rapid improvement of gas exchange, but SE became progressively larger. On the second day, several 2 cm skin incisions were made bilaterally in the subclavicular regions; immediately a loud hiss of escaping air was heard and the patient's condition improved rapidly. He was extubated after seven days and made a full recovery. Case 2. A 42-yr-old male was admitted to ITU three days after a street fight because of rapidly progressing SE, extending to the head, neck, chest, abdomen and legs. He was suffering from pneumomediastinum, pneumopericardium, and broken ribs, hyoid bone and Th10 spinous process. An emergency tracheostomy was performed and blow holes were made in both subclavicular regions. This resulted in rapid improvement and he was discharged home after two weeks in hospital.

Discussion and conclusion: Several methods of treatment for severe SE have been described, including pleural drainage, subcutaneous insertion of pig-tail drains, iv cannulas or large bore drains. The method described, albeit not always successful, is simple and can be applied in every setting.

Unlabelled: Pneumocephalus and pneumorrhachis are rare findings, and may result from a variety of causes, including severe asthma or trauma. We describe a case, where intracranial and intraspinal air was found after trauma to the chest wall.

Case report: A 24-yr-old patient suffered multiple trauma in a traffic accident, including a closed head injury and bursting fractures of theTh 7, 8 and 9 vertebral bodies with laceration of the spinal cord. Reposition of the spinal column was complicated by wound infection and septic shock. Intraoperatively, accidental extubation led to migration of gastric contents and was complicated by possible rupture of the oesophagus. Postoperative CT scan revealed the presence of air within the mediastinum, cranium and the entire spinal canal. The osteosynthetic material was removed, and the air quickly reabsorbed. The paraplegic patient was discharged from ITU in a satisfactory condition.

Discussion: The most probable cause of the complication was traumatic rupture of the oesophagus and penetration of air via lacerated dura mater, to the spinal canal and the cranium. Conservative treatment was successful and led to complete (beside paraplegia) recovery.