[Serious sepsis treatment in intensive care departments in the Czech Republic -  EPOSS Project pilot results]. / Lécba tezké sepse na pracovistích intenzivní péce v Ceské republice -  pilotní výsledky projektu EPOSS.

INTRODUCTION: Severe sepsis is still associated with significant morbidity and mortality, which is however different, as well as its management, depending on the region. What is the situation in the Czech Republic and what is the character of patients with severe sepsis is currently not known. The aim of the project is to describe the processes of care, outcome and characteristics of patients with severe sepsis admitted to the intensive care department of the Czech Republic. METHODS: This is a multicentre and observational project with retrospective enrollment of patients who meet the criteria for severe sepsis before or within 24 hours after admission to selected intensive care units (ICU EPOSS). RESULTS: 394 patients were analyzed. Median age at admission was 66 (56- 76) years, males predominated (58.9%) and the median APACHE II score on admission was 25 (19- 32). Patients were predominantly medical (56.9%) and most were secondary admitted from other ICU (53.6%). Meeting the criteria of severe sepsis was most frequently within the period (± 4 hours) of admission the EPOSS ICU (77.6%). Median total fluid intake during the first 24 hours was 6,680 (4,840- 9,450) ml. Most patients required mechanical ventilation (58.4%). Compliance with the resuscitation bundle of severe sepsis in our group was very good and was associated with lower mortality of patients. Most frequently, the EPOSS ICU length of stay (LOS) was 7 (3- 15) days and median hospital LOS was 13 (8- 28) days. Hospital mortality in our cohort was 35.8%. CONCLUSION: Introducing the project, which in its first stage obtained valuable and internationally comparable data about patients with severe sepsis admitted to the involved ICU in the Czech Republic.

[Peripartal life-threatening hemorrhage - interdisciplinary consensus opinion]. / Peripartální zivot ohrozující krvácení - mezioborové konsenzuální stanovisko.

22 experts from the fields of gynecology and obstetrics, anesthesiology and resuscitation, intensive care, hematology and transfusion medicine has developed recommendations for diagnosis and procedure for life-threatening peripartum haemorrhage, which is still one of the most common causes of maternal mortality in childbirth. This guidelines, which is valid for the Czech Republic, supported by a total of 10 professional medical societies. There are based on new knowledge applicable at this time and is focused mainly on eliminating the most common causes of bleeding during delivery and prevention of haemorrhagic shock.

Anaesthesia workforce in Europe.

BACKGROUND AND OBJECTIVE: The European anaesthesia workforce is facing increased demand and expansion of the labour market, which may likely exceed supply. This survey assesses the numbers and practice patterns of anaesthesiologists and studies migration and shortage of the anaesthesia workforce in Europe. METHODS: A questionnaire was sent to all national European anaesthesia societies. Countries were grouped according to their relationship with the European Union. RESULTS: The number of anaesthesiologists per 100,000 population varies between 2.7 (Turkey) and 20.7 (Estonia). There seems to be no clear evidence for feminization of the anaesthesia workforce. Anaesthesia physician training lasts between 3 yr (Armenia, Belarus, Uzbekistan) and 7 yr (Ireland, UK), and seems to positively correlate with the number of trainees. Throughout Europe, anaesthesiologists typically work in public practice, and are involved in the entire care chain of surgical patients (anaesthesia, intensive care, chronic pain and pre-hospital emergency medicine). The differences between European salaries for anaesthesiologists are up to 50-fold. Most Western European countries are recipients of migrating anaesthesiologists who often originate from the new member states of the European Union. However, it seems that expectations about anaesthesia workforce shortages are not confined to Eastern Europe. CONCLUSIONS: Each European country has its own unique workforce constellation and practice pattern. Westward migration of anaesthesiologists from those countries with access to the European Union labour market may be explained by substantial salary differences. There is a European-wide lack of systematic, comparable data about the anaesthesia workforce, which makes it difficult to accurately assess the supply of anaesthesiologists.

Antibody formation against beta-tubulin class III in response to brain trauma.

Brain trauma typically leads to neuronal damage and loss. Assuming a transient autoimmune response to debris of the damaged neurones, we have monitored serum titres of IgG and IgM antibodies to beta-tubulin class III (betaTcIII), which is almost exclusively found in neuronal cytoskeletons. In 15 out of 18 patients, the peak of the IgG or IgM antibody titre appeared in the serum within 3 weeks of a brain trauma.

[Intensive care for patients with severe acute pancreatitis with a significant multiorgan dysfunction]. / Intenzivní péce o nemocné s tezkou akutní pankreatitidou a významnou multiorgánovou dysfunkcí.

The aim of this retrospective study was to determine characteristic features of the onset and the course of the most severe forms of a severe acute pancreatitis with a concomittent multiorgan dysfunction syndrome. The study included patients transferred to the Intensive Care with a severe acute pancreatitis diagnosis and with a respiratory, circulatory and renal insufficiency or coagulopathy, or with the combination of the above. During the period from VII/1997 to XII/2002, 23 patients were treated. The mortality rate reached 78%. The average APACHE II score on admission was 23 in survivors, and 27 in no-survivors. Continuously high SOFA score (p < 0.05), more significant circulatory instability during the first days of the treatment, expressed by a higher need for the adrenaline use, and continuously increased CRP values during the follow-up treatment (day 7-14, p < 0.05), all of it signalized unfavourable results. In 50% of the fatal cases, renal insuficiency, requiring the use of the extracorporeal elimination method was reported while, on the other hand, none of the survivors suffered from renal insufficiency. The unfavourable course of the condition was also characterized by a need for more intensive therapies: those, who exited, had been cathetrized more often and they had required more surgical interventions. A favourable turn in the course of the disease was signalized by a drop in the serum CRP and by a decreasing need for vasopressors medication.

The effects of cardiopulmonary bypass with hollow fiber membrane oxygenator on blood clotting measured by thromboelastography.

In cardiac surgical patients we investigated the effects of cardiopulmonary bypass (CPB) with a hollow fiber membrane oxygenator on blood clotting measured by thromboelastography (TEG). We found only a minimal change in the strength of blood clot described either by the TEG parameter MA (maximum amplitude) or by the shear modulus G calculated from MA. After CPB there was also a significant tendency towards hypercoagulation as defined by shortened parameters R, K and increased a-angle. After comparison with published data obtained in cardiac surgical patients using a bubble oxygenator we conclude that currently used extracorporeal technology exerts a less negative influence on blood clotting than had been conceived previously.

[Nitric oxide in the treatment of acute respiratory distress syndrome]. / Uzití oxidu dusnatého ke zvládání syndromu akutní dechové tísne.

BACKGROUND: Nitric oxide (NO) is a selective pulmonary vasodilator effective in the treatment of pulmonary hypertension and hypoxemic respiratory failure. Reports in the Czech literature on the results of its therapeutic use are still scarce. METHODS AND RESULTS: Effects of inhaled NO on the changes of PaO2/FiO2 were assessed in the retrospective study. Records of artificially ventilated patients suffering from acute respiratory distress syndrome (ARDS) were reviewed. Daily highest NO dose, the highest PaO2/FiO2 ratio, duration of NO administration and death or survival of the patient was noted. Survivors and nonsurvivors, as well as responders (rise of PaO2/FiO2 by at least 20%) and non-responders were compared using Mann-Whitney and ANOVA test, alpha = 0.05. 16 patients were entered into the study, 13 (81%) responded positively to NO administration, the mortality was 56%. Comparing the age, NO dose, duration of its administration and APACHE II score in survivors and non-survivors, in respondents and non-respondents no differences were found. After NO administration the PaO2/FiO2 rose both in survivors and non-survivors (p < 0.0005). In survivors the response of oxygenation was more pronounced, although the difference did not reach the statistical significance (p = 0.07). On the days 1-3 the PaO2/FiO2 ratio was higher in survivors (p < 0.05). CONCLUSIONS: Despite the transient increase in oxygenation after NO administration, mortality of patients with ARDS remained high. NO administration could not be considered the standard method of treatment of patients with ARDS in intensive care.

[Respiratory insufficiency in the surgical intensive care unit]. / Respiracní insuficience na chirurgické JIP.

Postoperative pulmonary complications are of clinical importance: they prolong the hospitalization, increase the costs of treatment and contribute to the perioperative mortality. Respiratory insufficiency--inability to maintain adequate exchange of gases in the lungs--is its most severe form. Early diagnostics is essential and it is possible only during continuous and meticulous surveillance of the patient. In the postoperative period there are factors present enhancing the development of the postoperative pulmonary complications: drugs, pain, influence of the trauma of the operation, decreased lung capacity and decreased mobility. Prevention of complications is essential. Its indispensable part is adequate preoperative preparation, as well as good management of anaesthesia. The cornerstones of adequate postoperative care are oxygen therapy, sufficient analgesia, physiotherapy. At the earliest signs of respiratory insufficiency the commencement of respiratory support is mandatory. Artificial ventilation can be used as a preemptive measure preventing the development of pulmonary complications.

[Aprotinin (Antilysin Spofa)--its effect on decreasing hemorrhage in the postoperative period in hip arthroplasty]. / Aprotinin (Antilysin Spofa)--jeho úcinek pri snizování krvácení v pooperacním období u pacientu s náhradou kycelního kloubu.

PURPOSE OF THE STUDY: Aprotinin is a non-specific inhibitor of serine proteases with hemostyptic and hemostatic properties. The effect covers suppression of fibrinolysis and support of the role of thrombocytes in coagulation. In a prospective randomized study we verified whether the application of aprotinin (Antilysin Spofa, Czech Republic) in the dosage effective in cardiosurgical patients reduces blood loss and the need for blood transfusion for orthopaedic patients. MATERIAL: 42 patients indicated to the primary THA were randomly selected into the study and control groups. Excluded were allergic patients and those who used aprotinin before. METHODS: Administration of 2.10(6) KIU of aprotinin was started preoperatively and is continued in the course of the first hour of surgery. In the operated on patients we recorded prior to operation and in the first post-operative morning the level of hemoglobin in blood and hematocrit, the number of infusions and blood transfusion units administered in the course of the surgery and in the post-operative period until the first post-operative morning. We recorded blood loss in the period between the surgery and the first post-operative morning. Data acquired in the patients of the studied and control groups were compared by means of ANOVA test for repeated measuring and with the use of Mann-Whitney and chi 2-test, the level of significance p < or = 0.05. During the hospitalization we the patients were checked for symptoms of deep venous trombosis and tromboembolic or other adverse events. RESULTS: Hemoglobinemia and hematocrit in both groups significantly decreased after the operation (p < 0.0005), the differences between the studied and control groups were not significant. The number of administered blood units did not differ in the examined and control groups. The frequency of blood transfusions was postoperatively higher in the control group (59.1% as compared to 30%), however, the difference was not statistically significant (p = 0.059). Blood loss in the post-operative period was higher in the control group (p = 0.048). Patients from the control group got in total blood transfusion more frequently (p = 0.032). Differences in the total frequency of blood transfusion and in the amount of post-operative blood loss were statistically significant. In the course of hospitalisation no signs of deep phlebothrombosis or thromboembolic condition were encountered in either group of patients. Complications were not recorded. DISCUSSION: Our results correspond with most of the published data. Blood loss of the operated on patients who were administered prior to and at the beginning of the operation in total 2.10(6) KIU of aprotinin (Antilysin Spofa) in infusion was on average by 33% less in the post-operative period and in the whole peropetive period they required less frequently blood transfusion (40% vs 73%). CONCLUSION: Infusion of aprotinin (Antilysin Spofa) in the dosage of the order of 106 KIU significantly reduces post-operative blood loss and frequency of transfusion in the peroperative period in patients undergoing THA.

Gastric tonometry and intramucosal pH--theoretical principles and clinical application.

Gastric or intestinal luminal tonometry is a method for monitoring critically ill patients. It offers an index of the adequacy of aerobic metabolism in a tissue that is particularly sensitive to alterations in its perfusion and oxygenation: the gut mucosa. It is based on the measuring the increase in tissue CO2 production that accompanies anaerobic metabolism. The method simply consists of a balloon in the stomach, which measures intramucosal pCO2. From this measurement and from the arterial bicarbonate concentration gastric intramucosal pH (pHi) can be calculated, assuming that bicarbonate concentration in the gastric mucosal tissue is in equilibrium with systemic arterial bicarbonate. Despite possible clinical benefit from the measurement and the therapy of low pHi values in critically ill patients, the theoretical, experimental and pathophysiological implications for the monitoring of intramucosal acidosis in the gut are not yet fully understood. There are still some open methodological questions crucial for further clinical interpretation.

A retrospective survey of fibrinolysis as an indicator of poor outcome after cardiopulmonary bypass and a possible early sign of systemic inflammation syndrome.

A retrospective survey was undertaken of 142 adults who had undergone cardiac surgery with cardiopulmonary bypass. According to the manufacturer's instructions for thromboelastography, patients were identified as showing evidence of fibrinolysis if after coming off bypass the Ly30 index was > or =7.5%. In the 20 fibrinolytic patients, fibrinolysis was readily corrected by tranexamic acid but these patients needed more colloid and more vasopressor support than the non-fibrinolytic patients. There were three deaths, all in the fibrinolytic patients. It is possible that fibrinolysis is a marker for onset of systemic inflammation syndrome. It is recommended that, until the association between fibrinolysis and worse outcome is investigated further, patients showing fibrinolysis early after cardiopulmonary bypass should not be discharged too soon from intensive care.

[Thromboelastography--an instrument for the researcher or clinician?]. / Tromboelastografie--nástroj výzkumníka nebo klinika?

Thromboelastography is a method which is used experimentally since 1948. Since the end of the eighties it is experiencing a certain revival also in clinical medicine. The submitted case-record presents this technique as a very useful aid in the differential diagnosis of postoperative haemorrhagic conditions in cardiosurgery. Its application can facilitate aimed treatment of some typical disorders of haemocoagulation.

[Direct myocardial revascularization by antero-lateral minithoracotomy]. / Prímá revaskularizace myokardu z anterolaterální minitorakotomie.

The authors present the case of successfully treated patient with CAD, operated from left anterolateral minithoracotomy. Angiographic control two years later presents fully patent anastomosis without any signs of stenosis.

[Minithoracotomy in cardiac surgery. Initial experience with closure of an atrial septal defect with a minithoracotomy]. / Minitorakotomie v kardiochirurgii. První zkusenosti s uzáverem defektu sínového septa z minitorakotomie.

The authors describe their own modification of closure of an atrial septal defect (ASD) from right anterolateral minothoracotomy. This minimally invasive approach was selected in girls and women. Right anterolateral thoracotomy was used in 1987 to 1994 in twelve female patients. With regard to the general trend towards aesthetic surgery the authors use at present minimal anterolateral right-sided thoracotomy which with regard to its close relationship with the right atrium makes a safe surgical access to the atrial septum possible. Extracorporeal circulation is implemented by cannulation of the iliac artery in the groin, venous return is ensured by cannulas inserted into the venae cavae in the surgical field (by the auricle of the right atrium into the vena cava superior and the right atrial wall into the vena cava inferior). The operation itself is performed with electric fibrillation of the heart and tightening of the venous tourniquets. Between January 1995 till March 1996 the authors made by the thus modified approach a closure of the ASD type secundum in four female patients age 17, 29, 35 and 40 years. ASD was located always in the fossa ovalis and was repaired by direct suture. The duration of the extracorporeal circulation was on average 30 minutes. The length of the skin incision was 8-10 cm. The operation was free from complications. The cosmetic result is excellent and is consistent with principles of aesthetic surgery. If an arterial cannula is inserted into the groin minithoracotomy can be recommended for closure of ASD with extracorporeal circulation as a safe method.

[Radical anatomic correction of transposition of great arteries in neonates. A new program of treatment of critical congenital heart defects]. / Radikální anatomická korekce transpozice velkých arterií u novorozencu. Nový program lécby kritické vrozené srdecní vady.

METHODS AND RESULTS: From the group of 110 neonates born with transposition of the great arteries during 1991-1994 that were referred for the treatment to Kardiocentrum, University Hospital Prague-Motol, 46 neonates with simple transposition were operated on according to the criteria for anatomical correction (arterial switch) at the mean age of 9 days (4-20 days). Fourteen infants with transposition and large ventricular septal defect were corrected with arterial switch at the mean age of 2.5 months (5 weeks-9 months). Fifty neonates that did not meet criteria for arterial switch procedure were indicated for correction at the atrial level (Senning procedure) that has been performed at the mean age of 5 months (1-10 months). Out of 46 operated neonates 10 died following the operation and one child died 2 months later after surgery. There were 2 death out of last 20 neonates (10%). Thirty five children surviving 1-4 years after anatomical arterial correction of transposition are without complaints in excellent condition, NYHA class I. CONCLUSIONS: The procedure of the anatomical correction at the level of the great arteries (arterial switch) according to Jatene, that has been successfully introduced at Kardiocentrum, University Hospital Prague-Motol, has been reproducible and became the method of choice for operations of transposition of the great arteries in neonates with the suitable anatomy.