Anestezjologia intensywna terapia最新文献

Background: Premedication reduces requirement for anaesthestic agents during anaesthesia. There have been few papers published on the effects of clonidine on the MAC of volatile agents. The aim of this study was to assess the effects of premedication with midazolam or clonidine on remifentanil and sevoflurane requirements, necessary to achieve an adequate level of anaesthesia, in patients undergoing laparoscopic cholecystectomy.

Methods: ASA I and II patients were randomly allocated to three groups. Two groups received premedication with either 150 mg of clonidine, or 7.5-15 mg of midazolam. The third group received a placebo. All patients were induced with remifentanil and sevoflurane, and intubated after relaxation with rocuronium. The sevoflurane concentration was adjusted to achieve entropy values between 60 and 50. Analgesia was maintained with remifentanil via infusion at a rate of 0.05-0.15 microg kg(-1) min(-1).

Results: Sixty patients were enrolled to the study. The concentration of sevoflurane necessary to maintain entropy between 55 and 60 was statistically lower in the midazolam group than in the placebo group (p = 0.006) or the clonidine group (p = 0.02). No statistically significant differences in remifentanil requirements were observed. The recovery time was shortest in the placebo group (p < 0.05), slightly longer in the clonidine group (p > 0.05), and longest in the midazolam group (p < 0.05).

Conclusions: Clonidine did not affect the MAC of sevoflurane and remifentanil requirement. Midazolam decreased the time taken for induction of anaesthesia.

Background: Pneumonia and malnutrition are two of the biggest killers in childhood, as defined by the World Health Organisation. Although common in the developing world, these conditions can also be observed in more advanced countries, as a result of negligence and lack of proper care in disabled children. We describe a case in which severe malnutrition resulted in multiple organ failure.

Case report: A 16-yr-old retarded girl with +14q chromosome aberration, was admitted to hospital because of severe anaemia and dyspnea. She was extremely malnourished. Her body weight was 32 kg with a height of 152 cm (BMI 13.9). Her Hb concentration was 1.12 mmol L(-1), Ht 7%, and RBC 0.93 T L(-1). RBC transfusion resulted in transfusion-related acute lung injury (TRALI) and multiple organ failure. She was treated with mechanical ventilation, inotropic support and parenteral nutrition, complicated by the refeeding syndrome and gastrointestinal haemorrhage. After recovery, a gastrostomy was performed, but due to gastric retention she required a laparotomy for adhesiolysis.The girl recovered and remains under home care.

Discussion: In a case of a girl with retardation, multiple organ failure resulting from ten years of malnutrition was observed. She was especially difficult to treat because of a prolonged dysfunction of homeostasis, hypoproteinemia, hypophosphatemia and SIRS. Such patients require careful treatment in ICU settings.

Background: A thyroid storm--a sudden, life-threatening exacerbation of thyrotoxicosis--can lead to multiple organ failure due to hyperactivity of the sympathetic nervous system. Symptoms may include fever, tachycardia, cardiovascular collapse, myocardial infarction, hepatic failure, cerebral infarction, delirium, coma, and rhabdomyolysis. Various therapies have been proposed for the management of thyrotoxicosis. They include: reduction of sympathetic outflow (beta-blockers); decreased production and release of thyroid hormone (thiamazole, propylthiouracyl, or iodine solution); and peripheral conversion of T4 to T3 (beta-blockers and steroids).

Case report: We present a case report of an atypical thyroid storm accompanied by multiple organ failure including coma, myocardial infarction, shock, respiratory failure and liver dysfunction. A 51-year-old female was admitted to the emergency department because of multiple organ failure. On admission the patient was unconscious, hypotensive, acidotic and hyperkalemic. Her core temperature was 37.6 degrees C, and she had an LVEF of 30%. Thyroid function tests showed thyrotoxicosis: the fT3 concentration was 17.3 pmol L(-1) (ref. range 2.3-6.3), fT4 50.4 pmol L(-1) (ref. range 10.3-24.4), and TSH 0.009 microU mL(-1) (ref. range 0.4-4.0). SGOT and SGPT concentrations were also increased. The electrocardiogram showed an elevated ST in leads II, III, aVF, and V2 to V5. Troponin I concentration was 5.1 ng mL(-1) (ref. range < 0.05). An emergency coronary angiogram revealed normal perfusion. Treatment was started with vigorous inotropic support(dopamine, dobutamine and norepinephrine, followed by intraaortic balloon counterpulsation. She also received thiamazole, beta-blockers, iodine solution, glucocorticoids and diuretics. On the 8th day, a subtotal thyroidectomy was performed. The patient was weaned from mechanical ventilation after 14 days and recovered without any neurological deficit.

Conclusion: The described case showed that a thyroid storm can present as multiple organ failure, requiring intraaortic balloon counterpulsation for the management of catecholamine-resistant shock.

In Poland, two types of medical services are accomplished by the Medical Air Rescue (MAR) operating all over the country: emergency transport from the incident scene to hospital and inter-hospital transport. Helicopters or planes are used for this purpose. In 2009, helicopters performed 4359 flights to incidents and 1537 inter-hospital transports whereas planes performed 589 inter-hospital ambulance and 196 rescue flights. MAR operates from 17 bases of the Helicopter Emergency Medical Service (HEMS) and one airbase. Helicopters are mainly used when medical transport is emergent, within the operational region of a given base whereas planes when the distance between the present and target airports exceeds 250 km. In 2008, new modern aircraft were introduced to HEMS-helicopters EC 135. They fulfil all requirements of air transport regulations and are adjusted to visual (VFR) and instrumental (IFR) flights rules, at day and night. The medical cabin of EC 135 is ergonomic and functional considering the majority of rescue activities under life-saving circumstances. It is equipped with ventilator, defibrillator, infusion pumps etc. Defibrillators have 12-lead ECG, E(T)CO2, SpO2, NIBP, and IBP modules. Transport ventilators can work in a variety of ventilation modes including CMV, SIMV, SVV, BILEVEL, PCV, ASB, PPV and CPAP. The purchase of helicopters with modern avionic and medical configuration ensures high quality services of MAR for many years to come.

Plasmapheresis or therapeutic plasma exchange is a procedure designed to deplete the body of blood plasma without blood cells. Whole blood is removed from the body, the plasma is separated from the cells, and the cells are suspended in saline before being returned to the patient. The procedure is used to remove excess antibodies, immunoglobulins, or cytokines from the blood in various clinical situations. The particles removed should be adequately large (>15 kDa) and have a relatively long half-life. The volume of removed plasma should be based on body weight and haematocrit, and in an adult patient be in range of 2.5-2.7 litres (30-40 mL kg(-1)). To remove 90% of a harmful substance, four to five exchanges are necessary. In the review, several modes of plasmapheresis are described. The most common indications for plasmapheresis in patients treated in an ITU are: thrombotic thrombocytopenic purpura, Waldenström macroglobulinemia, Guillain-Barre syndrome, chronic inflammatory poliradiculopathy, myasthenia gravis, or Lambert-Eaton syndrome.The procedure is safe, and complications are rare and not serious.

Background: The cost of nursing in a modern hospital can take up to 50% of the total budget. Therefore, it is very important to use objective tools for assessment of the nursing workload and adjust staff requirements accordingly. The purpose of the study was to evaluate nursing workload using the Nursing Activities Score (NAS) in intensive care units.

Methods: This prospective analysis of nursing care of 314 adult patients was performed simultaneously in five intensive care units in Poland. NAS was used for the evaluation of nursing workload and the APACHE II score was used for assessment of the severity of cases. The APACHE score was calculated during the first 24 hours of ICU stay, while the NAS was recorded over an entire stay.

Results: The average age of the patients was 58.4 +/- 16.6 years. The length of stay was 8.7 +/- 11.4 days. The distribution between surgical (56%) and non-surgical cases (44%) was almost equal. Mortality was 21%. The median APACHE II score was 20 (1-42) and the NAS score 84.4%. There was no correlation between patients' clinical condition and nursing workload (p > 0.05), and the workload in surgical and non-surgical patients. The NAS score correlated well with the length of stay (p < 0.05).

Conclusion: The study showed that ICU nurses spend 84.4% of their working time by the patient's bed. The optimal ICU nurse: patient ratio was estimated to be 1:1.2.

Background: Intensive therapy units are the places where pathogens can easily spread. Improper antibiotic therapy contributes to the selection of new strains called multidrug-resistant, extensively drug-resistant or pandrug-resistant. For ITU patients, such pathogens are particularly dangerous.

Case report: The case of a 50-year-old man diagnosed with septic shock after repeated surgeries due to Vater's ampulla tumour was described. In blood and peritoneal fluid cultures, Enterobacter cloacae ESBL and Klebsiella pneumoniae were first isolated; then Acinetobacter baumannii was also detected. The targeted antibiotic therapy instituted did not bring the expected results. On day 5, tigecycline and imipenem were started and continued over 10 days. After 4 days of combined therapy, bacterial strains were eradicated. The patient was sent to the referring ward in good condition.

Conclusion: Combined use of imipenem and a new antibiotic - tigecycline provides effective treatment of septic shock in the course of intra-abdominal infection.

Background: The occupational exposure to inhalation anaesthetics in operating rooms, and its effect on hospital staff, have been widely discussed. The first national survey, published in Poland several years ago, revealed worrying levels of contamination, especially in hospitals with poorly equipped operating rooms. The purpose of this recent survey was to assess contamination of the operating room air under various conditions.

Methods: The survey questionnaire was sent to 484 hospitals, of different levels of referral, in Poland between October 2006 and January 2007. The questions in the questionnaire referred to anaesthetic techniques, technical infrastructures of operating rooms, and quality of anaesthetic equipment.

Results: Two hundred and seventy surveys were returned (55.8%), providing information about 1280 operating rooms.They revealed a major deficit in essential infrastructures and anaesthetic equipment in operating rooms, especially in regional hospitals. In addition, an important human factor was revealed, with many anaesthesiologists found to be using out-dated, air polluting methods of anaesthesia.

Conclusions: Operating room air contamination with inhalation anaesthetics still poses a major risk in Polish hospitals, because of poor infrastructure and lack of modern anaesthetic equipment. The risk factors are related to the hospital referral level, but not to their geographic location.

Background: The highest percentage of patients treated in ITU is diagnosed with infections, including nosocomial infections. Proper and early instituted antibiotic therapy decreases the mortality rates, duration of ITU stay and treatment-related costs. The therapy should be based on antibiotic susceptibility of cultured pathogens and the pharmacokinetic/pharmacodynamic profile of drugs used.

Method: The efficacy of antibacterial therapy with cefoperazone/sulbactam was retrospectively assessed by ITU patients assigned to four groups: I--out-of-hospital pneumonia, II--severe sepsis/septic shock, III--COPD and IV--others. Immediately after admission the bronchial tree secretion and blood were collected for microbiological diagnosis; the initial dose of antibiotic 2 g was started and continued with 4 g in the 24-hour infusion.

Results: The analysis involved medical records of 80 out of 560 patients; 71.25% had cefoperazone/ sulbactam-susceptible pathogens. The level of C-reactive proteins decreased in 78% of group I and II patients, in 67%--group III and in 46% of group IV. Mortality in the entire group of 80 patients was 26.2% compared to 51.4% in the total population treated in ITU.

Conclusion: Continuous infusion of cefoperazone/sulbactam applied to selected ITU patients can effectively treat different types of in- and out-of-hospital infections.

Background: The Tako-Tsubo syndrome is characterized by a transient left ventricular dysfunction in the absence of obstructive coronary disease, typically precipitated by severe emotional or physical stress. It is characterized by a balloon-like left ventricular appearance on angiography, ECG changes, and elevated cardiac biomarkers. We describe a case, where Tako-Tsubo cardiomyopathy was diagnosed in a patient with subarachnoid haemorrhage.

Case report: A 57-year-old man was brought to the hospital after cardiac arrest and successful resuscitation. After admission, echocardiography was performed that revealed marked impairment of contractility of the left ventricle with akinesis of the apex, interventricular septum, and anterior wall. Subsequent coronary angiography revealed neither coronary pathology nor pulmonary embolism; however, ventriculography showed typical dynamics of the Tako-Tsubo syndrome. Because of a deep cerebral coma (GSG 3), a CT-scan was performed that revealed subarachnoid haemorrhage with a haemotoma in the left temporal lobe, together with symptoms of massive cerebral oedema. The patient died eight days later despite vigorous intensive care. During the autopsy, a ruptured aneurysm of the left central cerebral artery was found.

Conclusions: The Tako-Tsubo syndrome may occur not only during serious stress but also after resuscitation of cardiac arrest following cerebral bleeding.