Pharmacological options in treating SASR-CoV-2 infection/COVID-19 / [Farmakoterápiás lehetoségek SARS-CoV-2-fertozés/COVID­19-betegség esetén]

There is currently no proven effective therapy for COVID-19. Here we discuss the drugs most investigated for the treatment of the disease. All the listed therapies are experimental at this stage. However, due to the severe healthcare effects of the pandemic and the potentially fatal outcome of COVID-19 patients treated in the intensive care units, their off-label use should none-the-less be considered. Orv Hetil. 2020; 161(17): 685­688.

Practical aspects of intensive care for critically ill COVID-19 patients requiring respiratory support / [Kritikus állapotú, légzéstámogatást igénylo COVID­19-fertozött beteg ellátásának gyakorlati szempontjai]

In December 2019, a novel outbreak of pneumonia was reported in Wuhan city, China. Initially, the zoonitic infection spread from human to human, causing a pandemic. This viral disease (COVID-19) can appear in a variety of forms, from asymptomatic through the spectrum of mild symptoms to severe respiratory failure, requiring intensive care. Caring for this latter group of patients puts a significant burden on health care. The purpose of this summary is to present the practical aspects of intensive care for patients requiring respiratory support and mechanical ventilation. Orv Hetil. 2020; 161(17): 678­684.

Practical aspects of anesthetic and perioperative care for COVID-19 patients / [A COVID­19-fertozött betegek anesztéziájának és perioperatív ellátásának gyakorlati szempontjai]

Caring for those affected by the coronavirus outbreak of December 2019 imposed a heavy burden on healthcare systems. Not only because some patients require intensive care, but because patients with any form of the disease may need surgical intervention. Managing these cases is a major challenge for anesthesiologists. The purpose of this summary is to present the practical aspects of anesthetic and perioperative care for patients requiring surgical treatment. Orv Hetil. 2020; 161(17): 692­695.

Airway management of coronavirus-infected patients / [Légútbiztosítás koronavírus-fertozött betegekben]

The coronavirus pandemic is a serious challenge for healthcare workers worldwide. The virus is spread through the air by droplets of moisture when people cough or sneeze and it has a very high virulence. Procedures generating airway aerosols are dangerous for every participant of patient care. The serious form of coronavirus infection can cause progressive respiratory failure. The best treatment is early endotracheal intubation and invasive mechanical ventilation. Intubation is an aerosol-generating process and thus carries the risk of contamination. Additionally the airway management of this patient population is usually difficult. The goal of this article is to give a practice-based overview of the peculiarities of airway management in coronavirus-infected patients with special regard to infection control and patient safety considerations. Orv Hetil. 2020; 161(17): 696­703.

Organ replacement therapy and life-supporting treatment modalities in critically ill COVID-19 patients / [Emelt szintu szervtámogató és életfenntartó kezelések kritikus állapotú COVID­19-fertozött betegeken]

In critically ill COVID-19 patients, the failure of the cardiorespiratory system can be due to one of the following: (1) cytokine storm, haemophagocytosis ­ septic shock, (2) unmanageable hypoxemia, (3) isolated organ failure or as part of multi-organ failure. Herein we give an overview of the therapeutic options for treating or preventing these disease states. In recent years, CytoSorb-haemoperfusion to remove cytokines has shown promising results in the treatment of septic shock. Inhalational nitric oxide (iNO), inhalational epoprostenol and veno-venous extracorporeal membrane oxygenation (ECMO) are options in severe hypoxemia that is unresponsive to conventional mechanical ventilation. Renal failure is a frequent component of the multi-organ failure usually seen with disease progression and necessitates starting one of the available continuous renal replacement modalities. Orv Hetil. 2020; 161(17): 704­709.

Intrahospital resuscitation of COVID-19 patients / [A COVID­19-betegek kórházon belüli újraélesztésének speciális szempontjai]

The coronavirus pandemic is a serious challenge for healthcare workers worldwide. The virus is spread through the air by droplets of moisture when people cough or sneeze and it has a very high virulence. Procedures generating airway aerosols are dangerous for every participant of patient care. Mortality of COVID-19 is above 10%, thus cardiopulmonary resuscitation is an often needed intervention in this patient group. Resuscitation is an aerosol-generating process and thus carries the risk of contamination. The goal of this article is to give a practice-based overview of the specialities of cardiopulmonary resuscitation in coronavirus-infected patients. Orv Hetil. 2020. 161(17): 710­712.

Reduced miR-26b Expression in Megakaryocytes and Platelets Contributes to Elevated Level of Platelet Activation Status in Sepsis.

In sepsis, platelets may become activated via toll-like receptors (TLRs), causing microvascular thrombosis. Megakaryocytes (MKs) also express these receptors; thus, severe infection may modulate thrombopoiesis. To explore the relevance of altered miRNAs in platelet activation upon sepsis, we first investigated sepsis-induced miRNA expression in platelets of septic patients. The effect of abnormal Dicer level on miRNA expression was also evaluated. miRNAs were profiled in septic vs. normal platelets using TaqMan Open Array. We validated platelet miR-26b with its target SELP (P-selectin) mRNA levels and correlated them with clinical outcomes. The impact of sepsis on MK transcriptome was analyzed in MEG-01 cells after lipopolysaccharide (LPS) treatment by RNA-seq. Sepsis-reduced miR-26b was further studied using Dicer1 siRNA and calpain inhibition in MEG-01 cells. Out of 390 platelet miRNAs detected, there were 121 significantly decreased, and 61 upregulated in sepsis vs. controls. Septic platelets showed attenuated miR-26b, which were associated with disease severity and mortality. SELP mRNA level was elevated in sepsis, especially in platelets with increased mean platelet volume, causing higher P-selectin expression. Downregulation of Dicer1 generated lower miR-26b with higher SELP mRNA, while calpeptin restored miR-26b in MEG-01 cells. In conclusion, decreased miR-26b in MKs and platelets contributes to an increased level of platelet activation status in sepsis.

[Open transgastric necrosectomy for extended walled-off pancreas necrosis]. / Kiterjedt, demarkált pancreas necrosis sebészi kezelése transgastricus necrectomiával.

AIMS: In severe acute pancreatitis the timing of necrosectomy is ideally should be postponed 4-6 weeks after the onset of the disease when the walled-of pancreatic necrosis (WOPN) has developed. The authors present their experience with open transgastric necrosectomy for extended WOPN. PATIENTS AND METHODS: The authors performed 17 (12 male, 5 female with a mean age of 61.6 ± 15.1 years) open transgastric necrosectomies for extended WOPN in a period of 1, January 2012 and 31, December 2017. Before the operations conservative and semiconservative therapy was used for an average of 74.6 ± 83.1 days. The mean size of the WOPNs was 13.8 ± 5.2 cm with localisation of the retrocolic and retroduodenal regions. All necroses were septic. RESULTS: Complications related to the operation were not observed. The mean time of hospitalization after the surgery was 11.6 ± 12.8 days. The mortality rate was 5.9%. Late operation or other interventions for pseudocyst or pancreas fistula formation was not performed. Two patients needed endoscopic dilatation with lavage in the early postoperative period because of fever. New diabetes mellitus was not observed but worsening of previously existed diabetes developed in 6.3% of the cases. CONCLUSIONS: The open transgastric necrosectomy is safe and effective for extended WOPN. The advantage of this type of necrosectomy is the prevention of pancreatic pseudocyst and fistula formation.

Hemodynamic consequences of intravenously given E. coli suspension: observations in a fulminant sepsis model in pigs, a descriptive case-control study.

BACKGROUND: The aim of the present work was to assess systemic hemodynamic changes using PiCCo monitoring in a porcine model of E. coli-induced fulminant sepsis. METHODS: Thirty-one healthy female Hungahib pigs were randomly assigned into control (n = 15) or septic groups (n = 16). In the sepsis group Escherichia coli culture was intravenously administrated in a continuously increasing manner according to the following protocol: 2 ml of bacterial culture suspended in physiological saline was injected in the first 30 min, then 4 ml of bacterial culture was administered within 30 min, followed by infusion of 32 ml bacterial culture for 2 h. Control animals received identical amount of saline infusion. Systemic hemodynamic parameters were assessed by PiCCo monitoring in both groups. RESULTS: Resting hemodynamic parameters were identical in the two groups. In control animals, systemic hemodynamic variables were relatively stable during the entire procedure. In septic animals shock developed in 165 (IQR: 60-255) min after starting the injection of E. coli solution. Blood pressure values gradually decreased, whereas pulse rate increased. A decrease in cardiac index, an increased systemic vascular resistance, and a decreased stroke volume variation were observed. CONCLUSIONS: These results may serve as additional pathophysiological information of hemodynamic changes occurring during hypodynamic sepsis and may contribute to a better understanding of the pathomechanism of septic multiple organ failure.

Pressure Distribution during Negative Pressure Wound Therapy of Experimental Abdominal Compartment Syndrome in a Porcine Model.

(1) Introduction: Negative pressure wound therapy (NPWT) is a frequently applied open abdomen (OA) treatment. There are only a few experimental data supporting this method and describing the optimal settings and pressure distribution in the abdominal cavity during this procedure. The aim of our study was to evaluate pressure values at different points in the abdominal cavity during NPWT in experimental abdominal compartment syndrome (ACS) animal model; (2) Methods: In this study (permission Nr. 13/2014/UDCAW), 27 Hungahib pigs (15.4-20.2 kg) were operated on. ACS was generated by implanting a plastic bag in the abdomen through mini-laparotomy and filled with 2100-3300 mL saline solution (37 °C) to an intraabdominal pressure (IAP) of 30 mmHg. After 3 h, NPWT (Vivano Med® Abdominal Kit, Paul Hartmann AG, Germany) or a Bogota bag was applied. The NPWT group was divided into -50, -100 and -150 mmHg suction groups. Pressure distribution to the abdominal cavity was monitored at 6 different points of the abdomen via a multichannel pressure monitoring system; (3) Results: The absolute pressure levels were significantly higher above than below the protective layer. The values of the pressure were similar in the midline and laterally. Amongst the bowels, the pressure values changed periodically between 0 and -12 mmHg which might be caused by peristaltic movements; (4) Conclusions: The porcine model of the present study seems to be well applicable for investigating ACS and NPWT. It was possible to provide valuable information for clinicians. The pressure was well distributed by the protective layer to the lateral parts of the abdomen and this phenomenon did not change considerably during the therapy.

Characteristics of thrombin generation in a fulminant porcine sepsis model.

INTRODUCTION: The activation of blood coagulation has been demonstrated in most cases of sepsis, however previous studies in humans could not detect hypercoagulability with global hemostasis assays. In a fulminant porcine sepsis model we analysed coagulation screening tests and thrombin generation to evaluate hemostatic alterations. MATERIALS AND METHODS: Live Escherichia coli bacteria were inoculated to female pigs and prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen were measured by coagulometry. Platelet counts, platelet aggregates and platelet phosphatidyl serine (PS) expression were studied, furthermore in in vitro experiments the PS-inducing ability of septic and control plasmas was investigated by flow cytometry. Thrombin generation was carried out by the Ascent Fluoroscan reader and results were evaluated by the Thrombinoscope software. RESULTS: Clotting assays showed a large variability, but no systematic changes during the 4-hour observation period. Platelet count significantly decreased and the number of platelet aggregates increased already by 2h compared to baseline values and to control animals. Although the increase in platelet PS expression was non-significant in the septic group, the septic plasma elicited PS expression on normal human red blood cells. Thrombin generation became significantly faster, but the quantity of formed thrombin demonstrated both hypo- and hypercoagulability depending on the setting of the assay. CONCLUSIONS: Enhanced thrombin generation without activators and the PS-inducing capacity of septic plasma are signs of hemostatic activation during fulminant sepsis while the decreased amount of generated thrombin upon tissue factor and phospholipid induced activation demonstrates attenuated thrombin forming ability.

Assessment of cerebral circulation in a porcine model of intravenously given E. coli induced fulminant sepsis.

BACKGROUND: The aim of the present work was to assess cerebral hemodynamic changes in a porcine model of E.coli induced fulminant sepsis. METHODS: Nineteen healthy female Hungahib pigs, 10-12 weeks old, randomly assigned into two groups: Control (n = 9) or Septic Group (n = 10). In the Sepsis group Escherichia coli culture suspended in physiological saline was intravenously administrated in a continuously increasing manner according to the following protocol: 2 ml of bacterial culture suspended in physiological saline was injected in the first 30 min, then 4 ml of bacterial culture was administered within 30 min, followed by infusion of 32 ml bacterial culture for 2 h. Control animals received identical amount of saline infusion. Systemic hemodynamic parameters were assessed by PiCCo monitoring, and cerebral hemodynamics by transcranial Doppler sonography (transorbital approach) in both groups. RESULTS: In control animals, systemic hemodynamic variables and cerebral blood flow velocities and pulsatility indices were relatively stable during the entire procedure. In septic animals shock developed in 165 (IQR: 60-255) minutes after starting the injection of E.coli solution. Blood pressure values gradully decreased, whereas pulse rate increased. A decrease in cardiac index, an increased systemic vascular resistance, and an increased stroke volume variation were observed. Mean cerebral blood flow velocity in the middle cerebral artery did not change during the procedure, but pulsatility index significantly increased. CONCLUSIONS: There is vasoconstriction at the level of the cerebral arterioles in the early phase of experimental sepsis that overwhelmes autoregulatory response. These results may serve as additional pathophysiological information on the cerebral hemodynamic changes occurring during the septic process and may contribute to a better understanding of the pathomechanism of septic encephalopathy.

Red blood cell and platelet parameters are sepsis predictors in an Escherichia coli induced lethal porcine model.

OBJECTIVE: In a fulminant porcine sepsis model, we determined the kinetics of hypoxia induced changes in relation to sepsis parameters and markers of organ damage. METHODS: Female pigs were challenged by live Escherichia coli and samples were analysed up to 4 hours. Bone marrow reactions were determined by analysing immature forms of peripheral blood cells by a hematology analyser and light microscopy. Platelet mitochondrial membrane depolarisation was determined by flow cytometry. RESULTS: Core temperature, modified shock index and lactate levels all became significantly elevated compared to baseline values at 4 hours in septic animals. At 2 hours already the reticulocyte count, nucleated red blood cell count and the absolute number of dysplastic platelets became significantly elevated. The platelet mitochondrial membrane depolarisation was significantly decreased by 2 hours in septic animals compared to the baseline values and to control animals. No massive organ damage was evident during the 4-hour observation period, but uric acid levels in septic animals became significantly elevated already by 2 hours. CONCLUSIONS: In this Escherichia coli induced porcine model, severe sepsis was evident by conventional criteria at 4 hours while several - mostly hypoxemia induced - biomarkers were already altered by 2 hours.

Horseshoe kidney transplantation.

Horseshoe kidney is a fusion anomaly found in approximately one in 400-600 people. Due to vascular and ureteral variations, transplantation with a horseshoe kidney presents a technical challenge. In our case, the isthmus connected the upper poles and contained parenchyma. It consisted of three renal arteries, five veins collected to the inferior vena cava, and two ureters and pyelons. It was implanted en bloc to the left side retroperitoneally. During the early period, cellular and humoral rejection was confirmed and treated. For a urine leak, double J catheters were implanted into both ureters. Later, the first catheter was removed. Subsequently, urinary sepsis developed, necessitating graftectomy. The uncommon anatomy of ureters and antibody-mediated rejection (AMR) may both be factors for a ureter tip necrosis led to an infected urinoma. After other Hungarian authors, we also report a horseshoe kidney transplantation that was technically successful. However, after an adequately treated but severe acute humoral rejection, the patient developed sepsis, and the kidney had to be removed. We conclude that transplantation with horseshoe kidney is technically feasible but may increase the risk for urinary complications and resultant infections. Careful consideration of risk and benefit is advised when a transplant professional is faced with this option.

Early hemorheological changes in a porcine model of intravenously given E. coli induced fulminant sepsis.

The pathophysiology of hemorheological and microcirculatory disturbances in septic process -mostly during the early hours- still not clarified in all the details, yet. In anesthetized pigs living E. coli (ATCC 25922 strain) was administered intravenously with an increasing concentration and the animals were observed for 8 hours. Before the intervention and in every 2 hours arterial (cannulated femoral artery) and venous (cannulated external jugular vein) blood samples were collected for hemorheological laboratory tests: blood and plasma viscosity, ESR, leukocyte anti-sedimentation rate, erythrocyte deformability (together with osmoscan parameters) and erythrocyte aggregation (using light-transmission and laser back-scattering methods) Control animals were stable over the 8-hour anesthesia, while septic animals died by the 6th hours in a fulminant sepsis. Over the experimental period, the tendency of impairment in erythrocyte deformability (together with osmotic gradient ektacytometry parameters) and the controversial decreasing of erythrocyte aggregation values (declining all aggregation index values, elongating t1/2) were well detected in this porcine model during the early hours (4- 6) of fulminant sepsis. The in vitro effect of these bacteria on erythrocytes' micro-rheological parameter was similar: decreasing red blood cell deformability and lowering aggregation. Further studies are needed to clarify the early micro-rheological changes of bacteremia and the developing sepsis.

Critical illness associated neuromuscular disorders -- keep them in mind.

Neuromuscular disorders complicating sepsis and critical illness are not new and scarce phenomena yet they receive little attention in daily clinical practice. Critical illness polyneuropathy and myopathy affect nearly half of the patients with sepsis. The difficult weaning from the ventilator, the prolonged intensive care unit and hospital stay, the larger complication and mortality rate these disorders predispose to, put a large burden on the patient and the health care system. The aim of this review is to give an insight into the pathophysiological background, diagnostic possibilities and potential preventive and therapeutic measures in connection with these disorders to draw attention to their significance and underline the importance of preventive approach.