Effect of lidocaine on intraoperative blood pressure variability in patients undergoing major vascular surgery.

BACKGROUND: Dynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in equal intervals allowing to assess its intraoperative variability, which significance for peri and post-operative period is still under debate. Lidocaine has positive cardiovascular effects, which may go beyond its antiarrhythmic activity. The aim of the study was to verify whether the use of intravenous lidocaine may affect intraoperative BPV in patients undergoing major vascular procedures. METHODS: We performed a post-hoc analysis of the data collected during the previous randomized clinical trial by Gajniak et al. In the original study patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive intravenous infusion of 1% lidocaine or placebo at the same infusion rate based on ideal body weight, in concomitance with general anesthesia. We analyzed systolic (SBP), diastolic (DBP) and mean arterial blood (MAP) pressure recorded in 5-minute intervals (from the first measurement before induction of general anaesthesia until the last after emergence from anaesthesia). Blood pressure variability was then calculated for SBP and MAP, and expressed as: standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and coefficient of hemodynamic stability (C10%), and compared between both groups. RESULTS: All calculated indexes were comparable between groups. In the lidocaine and placebo groups systolic blood pressure SD, CV, AVR and C10% were 20.17 vs. 19.28, 16.40 vs. 15.64, 14.74 vs. 14.08 and 0.45 vs. 0.45 respectively. No differences were observed regarding type of surgery, operating and anaesthetic time, administration of vasoactive agents and intravenous fluids, including blood products. CONCLUSION: In high-risk vascular surgery performed under general anesthesia, lidocaine infusion had no effect on arterial blood pressure variability. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04691726 post-hoc analysis; date of registration 31/12/2020.

Efficacy of Lidocaine Infusion in High-Risk Vascular Surgery-A Randomized, Double-Blind, Placebo-Controlled Single-Center Clinical Trial.

BACKGROUND: In perioperative pain control, adjuvants such as lidocaine can reduce opioid consumption in a specific type of surgery. The aim of this single-center prospective double-blinded randomized controlled trial was to determine opioid consumption in the perioperative period in patients receiving continuous lidocaine infusion. METHODS: Patients undergoing elective abdominal aorta and/or iliac arteries open surgery were randomized into two groups to receive 1% lidocaine or placebo at the same infusion rate based on ideal body weight (bolus of 0.15 mL/kg during the induction of anesthesia followed by continuous infusion of 0.2 mL/kg/h during surgery; postoperatively 0.1 mL/kg/h for 24 h) additionally to standard opioid analgesia. RESULTS: Total opioid consumption within 24 h after surgery was 89.2 mg (95%CI 80.9-97.4) in the lidocaine and 113.1 mg (95%CI 102.5-123.6) in the placebo group (p = 0.0007). Similar findings were observed in opioid consumption intraoperatively (26.7 mg (95%CI 22.2-31.3) vs. 35.1 mg (95%CI 29.1-41.2), respectively, p = 0.029) and six hours postoperatively (47.5 mg (IQR 37.5-59.5) vs. 60 mg (IQR 44-83), respectively, p = 0.01). CONCLUSIONS: In high-risk vascular surgery, lidocaine infusion as an adjunct to standard perioperative analgesia is effective. It may decrease opioid consumption by more than 20% during the first 24 h after surgery, with no serious adverse effects noted during the study period.

Risk factors of complications during noninvasive mechanical ventilation -assisted flexible bronchoscopy.

PURPOSE: Flexible bronchoscopy (FB) causes airway narrowing and may cause respiratory failure (RF). Noninvasive mechanical ventilation (NIV) is used to treat RF. Until recently, little was known about noninvasive mechanical ventilation assisted flexible bronchoscopy (NIV-FB) risk and complications. MATERIALS AND METHODS: A retrospective analysis of NIV-FB performed in 20 consecutive months (July 1, 2018-February 29, 2020) was performed. Indications for: FB and NIV, as well as impact of comorbidities, blood gas results, pulmonary function test results and sedation depth, were analyzed to reveal NIV-FB risk. Out of a total of 713 FBs, NIV-FB was performed in 50 patients with multiple comorbidities, acute or chronic RF, substantial tracheal narrowing, or after previously unsuccessful FB attempt. RESULTS: In three cases, reversible complications were observed. Additionally, due to the severity of underlining disease, two patients were transferred to the ICU where they passed away after >48h. In a single variable analysis, PaO2 69 â€‹± â€‹18.5 and 49 â€‹± â€‹9.0 [mmHg] (p â€‹< â€‹0.05) and white blood count (WBC) 10.0 â€‹± â€‹4.81 and 14.4 â€‹± â€‹3.10 (p â€‹< â€‹0.05) were found predictive for complications. Left heart disease indicated unfavorable NIV-FB outcome (p â€‹= â€‹0.046). CONCLUSIONS: NIV-FB is safe in severely ill patients, however procedure-related risk should be further defined and verified in prospective studies.

Comparing transpulmonary thermodilution monitoring to lung ultrasound during pneumonia: an observational study.

INTRODUCTION: Monitoring lung function during pneumonia is essential for the evaluation of the effectiveness of therapy in ICU patients. Among various bedside techniques, two particularly interesting are the lung ultrasound and the transpulmonary thermodilution technique. In this observational single center study we want to assess the correlation between the lung ultrasound examination (LUS) and transpulmonary thermodilution volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). MATERIAL AND METHODS: We analyzed data obtained from medical history of twelve patients requiring mechanical ventilation and hemodynamics monitoring with PICCO catheter due to newly diagnosed pneumonia. We compared lung ultrasound examination performed on the first and third day of new antimicrobial therapy with results of transpulmonary thermodilution examination made on same day. We also calculate the difference between values obtained on first and third day to compare the trends. RESULTS: We did not find any association between tested variables, except a correlation between PVPI and EVLWI, both measured at the same day (Rho = 0.3; 95%CI -0.02-0.59; p = 0.03), and trends in the period of 3 days (Rho = 0.6; 95%CI 0.2-0.8; p = 0.005). CONCLUSIONS: The results of the study indicate that volumetric values achieved using the PiCCO method as well as lung ultrasound should be interpreted with care and related to the clinical state of a patient, keeping in mind that no correlation between the result achieved and the actual state of inflammatory changes in the lungs may be possible.

Inter-arm differences in blood pressure among subjects with disseminated atherosclerosis scheduled for vascular surgery.

BACKGROUND: The measurement of blood pressure (BP) is routinely performed in perioperative care. The reliability of results is essential for the implementation of treatment ensuring haemodynamic stability. The aim of the present study was to assess the prevalence and basic determinants of inter-arm BP differences among patients with advanced peripheral atherosclerosis undergoing vascular surgical procedures of the lower limbs. METHODS: The prospective study was carried out in patients scheduled for elective lower limb vascular surgery. One-time non-invasive BP measurements were performed sequentially on the brachial arteries of both upper extremities before the induction of anaesthesia, maintaining the shortest possible interval between measurements. The systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded. RESULTS: The results of 173 patients (including 123 men aged 67 ± 8 years) were analysed. In 16 (9.3%) patients, an inter-arm difference in BP was already observed during the preoperative examination. SBP and DBP was higher in the right limb in 86 (49.7%) an 80 (46.3%) patients, respectively. Moreover, the medians of inter-arm differences in SBP, DBP and MAP were 9 (IQR 4-17), 5 (IQR 3-10) and 7 mm Hg (IQR 3-12), respectively. An evaluation of the determinants of BP differences related to the presence of additional diseases demonstrated that patients with arterial hypertension were characterised by higher SBP and MAP disproportions (P = 0.04 and P = 0.01). CONCLUSIONS: In the population of patients with disseminated atherosclerosis, the inter-arm differences in BP substantially exceed the measurement error limits and are likely to be associated with arterial hypertension. If in doubt about BP disproportions, intraoperative monitoring of BP should be recommended using an invasive method on the limb presenting higher non-invasively measured values.

Day and time of admissions to intensive care units - does it matter?

BACKGROUND: The literature data pertaining to the significance of day and time of ICU admission for outcomes of patients are inconsistent. The issue has not been analysed in Poland to date. The aim of the study was to gather information about differences between patients admitted to ICU outside regular working hours (off-hours) and those admitted during working hours (on-hours). METHODS: Analysis involved 20,651 patients from the Silesian Registry of Intensive Care Units carried out since 2010. The findings demonstrated that 34.8% of patients were admitted to ICUs during on-hours (between 8.00 a.m. and 3 p.m. on weekdays) and 65.2% were admitted during off-hours (outside regular working hours). The incidence of admissions and data of patients in both groups were compared in terms of the population characteristics and treatment outcomes. RESULTS: The incidence of admissions (calculated per each 24 hours of treatment) was found to be almost twice as high during on-hours, as compared to off-hours (14.5 vs. 6.9 patients/day). Patients admitted to the ICU during on-hours were less likely to be admitted from the surgical department (19.1% vs. 31.0%, P < 0.001), and more likely to be admitted from the emergency department (25.3% vs. 14.2%, P < 0.001). The incidence of off-hours admissions of cancer patients was lower (5.3% vs. 10.8%, P < 0.001), as compared with patients with alcohol dependence syndrome (10.3% vs. 6.9%, P < 0.001). Patients admitted during off-hours were in more severe conditions and had higher APACHE II scores (on average, 23.8 ± 8.8 vs. 21.8 ± 8.8, P < 0.001); their mortality rates were higher compared to the remaining population (46.8% vs. 39.4%, P < 0.001). CONCLUSIONS: Patients admitted to ICUs during off-hours are in more severe general condition and their treatment outcomes are worse, as compared to patients admitted to ICU during on-hours.

A single-centre seven-year experience with mechanical ventilation weaning.

BACKGROUND: Weaning from mechanical ventilation is a growing and challenging issue in modern intensive care medicine. We aimed to describe a 7-year experience in mechanical ventilation weaning of a single centre in Germany. METHODS: We retrospectively analysed data regarding 403 patients admitted between 2007 and 2013 with difficult or prolonged mechanical ventilation weaning. RESULTS: There were 261 men (64.8%) in the population. The median age was 72 (IQR 63; 77) years. The underlying reasons for ventilator dependence comprised: post-operative respiratory failure (56.3%), exacerbation of chronic obstructive pulmonary disease (14.4%) and pneumonia (7.4%). A tracheostomy was performed about 9 (IQR 7; 14) days after the last attempt of a spontaneous breathing trial, usually with the percutaneous method (89.3%). The median length of stay was 28 (IQR 20; 41) days. Sixty-five (16.1%) patients died. Among the survivors, complete ventilator independence was achieved in 316 (78.4%) subjects while 94 (29.7%) of them required a tracheal tube on discharge. The vast majority of patients were discharged to rehabilitation clinics (56.1%). All of the analysed parameters did not statistically significantly differ between consecutive years in the investigated period. CONCLUSION: Our initial results of mechanical ventilation weaning are encouraging, repeatable in subsequent years of observation and consistent with the literature data. Assessing the predictors of successful mechanical ventilation weaning requires further research.

Perioperative prognostic factors in patients with ruptured abdominal aortic aneurysms treated in the intensive care unit.

BACKGROUND: The incidence of abdominal aortic aneurysm has been estimated at 20-40 cases per 100,000 per annum. The disease is often asymptomatic; in many cases, its first symptom is shock caused by a ruptured aneurysm. The aim of the present study was to assess retrospectively the selected perioperative factors in patients hospitalised in the intensive care unit (ICU) after repair of ruptured abdominal aortic aneurysm. METHODS: Analysis involved medical records of patients after repair of ruptured abdominal aortic aneurysm treated in ICU in the years 2009-2010. Patients were divided into two groups: group I - survivors who were discharged from ICU and group II - non-survivors. Demographic factors, intraoperative data, vital parameters, laboratory results and severity of patient's state on admission to ICU were analysed. RESULTS: Analysis of laboratory results on admission to ICU showed lower values of pH and HCO(3)(-) concentrations as well as higher international normalised ratio (INR) and activated partial thromboplastin time (APTT) in group II. Mean intraoperative diuresis differed between the groups; in group I - 303 mL and in group II - 155 mL. Mean diuresis on ICU day 1 was higher in group I compared to group II, i.e. 20.87 and 11.27 mL kg b.w.-1, respectively. APACHE II, SAPS II, MODS and SOFA point values were higher in group I than in group II. CONCLUSIONS: Markers of impaired homeostasis, such as pH, HCO(3)(-) concentration, INR and APTT assessed on admission to ICU can be relevant prognostic factors in patients after repair of ruptured abdominal aortic aneurysm. Monitoring of diuresis during surgery and on day 1 of ICU treatment was a sensitive risk marker for acute kidney injury. Multiple organ failure scales such as APACHE II, MODS, SOFA and SAPS II were reliable prognostic tools to be used in the early period of ICU treatment.

[Vaccination against Streptococcus pneumonia and knowledge about it in the cardiology and general practitioners patients]. / Szczepienia przeciw Streptococcus pneumoniae i wiedza w tym zakresie pacjentów Poradni Kardiologicznej i Poradni Lekarza Rodzinnego.

UNLABELLED: Streptococcus pneumoniae is a reason of many infectious diseases, from prosy respiratory tract infections to the grave bacterial hematosepsis which often is a cause of patients death. Infection spreads with droplets or sometimes by direct contact. Symptomatic Staphylococcal infections most often unfold as a otitis, sinusitis, broncho-pneumonia and lobal pneumonia or as a chronic obstructive pulmonary disease, bronchial asthma aggravation or they can be the cause of many other illnesses like: meningitis and encephalitis, endocarditis, epicarditis, peritonitis, arthritis and hematosepsis. The aim of the study was to evaluate anti-streptococcal vaccinations and to analyze cardiology patients and General Practitioners patients knowledge about Streptococcus pneumoniae. MATERIAL AND METHODS: There were 312 Cardiology and General Practitioners patient's from Outpatients Clinic in Katowice included to the study. Additionally there were national registers analyzed involving anti-streptococcal vaccination and streptococcal infections data from years from 2006 to 2009. Informations about anti-streptococcal vaccination and data evaluating knowledge about streptococcal infections problems were obtained from the poll made especially for this study. RESULTS: Results of the study showed, that patient's knowledge about anti-streptococcal vaccination is very poor. From 312 patients included to the study only 16 were vaccinated and 118 persons had no knowledge about Streptococus pneumoniae. Data from the national registers showed, that in the years 2006-2009 the invasive form of streptococcal infection had similar number of patients - 273 and 274 respectively - in Silesia, 28 and 26 patients respectively. CONCLUSIONS: The knowledge about anti-streptococcal vaccinations is very poor and a number of people vaccinated small. There is the need to provide more information to rise the number of vaccinated persons, especially in the group of increased risk and consequently reduce worker absenteeism in the work and financial loss.

Left main disease management strategy: indications and revascularization methods in particular groups of subjects.

Surgical revascularization with coronary artery by-pass grafting is still recommended in vast majority of patients with unprotected left main disease. The aim of the paper was to analyze optimal treatment of left main disease in selected groups of patients, on the basis of current guidelines and information gained from literature data. We focused on data in relation to treatment of elderly patients, diabetics and those hemodynamically unstable. Additionally we discussed the issue of anti-platelet therapy and informed consent. As far as efficacy of treatment is concerned, not only method of revascularization but also general condition of the patient, the factors influencing peri-operative risk and optimal pharmacotherapy should be taken into account. Therefore establishment of the heart team is crucial when choosing the most suitable method of invasive treatment of left main disease.

[Vaccination against influenza--recommendations and reality in the assessments of patients of cardiology and family physician center]. / Szczepienia przeciw grypie--zalecenia a rzeczywistosc oceniane wsród pacjentów poradni lekarza rodzinnego i poradni kardiologicznej.

UNLABELLED: Influenza is one of the most common diseases in the world. It occurs seasonally and is a viral disease contracted by a direct contact (respiratory droplets), causing many serious complications. The best way to prevent influenza is to get vaccinated once a year, which is the cheapest and the most effective protection. Research results have confirmed positive effects of influenza vaccination in the group of patients above the age of 65 and under the age of five. The group of high-risk patients comprises people with chronic diseases, especially people suffering from chronic conditions like heart and lung diseases. The aim of the study was to evaluate influenza vaccination and influenza incidence rate. MATERIAL AND METHODS: Family Doctor Office and Cardiology Clinic patients were included to the study The source of data was questionnaire concerning anti-influenza avaccination and influenza occurrence. Another source of the data were records from the National Health Institute, the Public Sanitation Institute and the Warsaw Epidemiological Center. RESULTS: The research was conducted on a group of 312 patients. In this group, 134 people got vaccinated against the seasonal influenza (42.94%). Regular vaccination was declared by 78 patients (58.20%). 29 people had symptoms of influenza. From a group of higher-risk patients above the age of 65, 35 patients got vaccinated (51.47%). In this group only 3 people got ill (8.57%). CONCLUSIONS: According to research, not enough Poles get vaccinated against seasonal influenza. Moreover, not all of them do this regularly. Vaccinated people get ill less frequently than people who have not been vaccinated, which proves the effectiveness of vaccination. There is a need of further informative actions and wide-spread activities in order to increase the number of vaccinated people, especially from a higher risk group, which - based on the latest research results - is significant in a prevention of complications, including the development of acute coronary syndrome.

[Continuous veno-venous haemofiltration in adult intensive therapy]. / Ciagla hemofiltracja zylno-zylna u chorych leczonych w oddziale intensywnej terapii.

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.

[Results of severe sepsis treatment--two years of experience in a single centre]. / Analiza leczenia chorych z ciezka sepsa w Oddziale Anestezjologii i Intensywnej Terapii Górnoslaskiego Centrum Medycznego.

BACKGROUND: Treatment of severe sepsis (SS) is a major challenge for an ITU, because of the high mortality. The severity of 55 is scored according to the number of organ systems that have failed. We analysed the results of treatment of SS in the ITU of the Upper Silesian Medical Centre, and compared them to previously reported data obtained from other centres. METHODS: Between 2008 and 2009, 45 SS cases were treated. Demographic data, laboratory tests and therapeutic routines were analysed. RESULTS: The overall mortality rate was 58%. There was a positive correlation between mortality, male gender and advanced age. The most common initial sources of infection were the respiratory system and abdominal cavities. Serious metabolic disturbance and central nervous system failure markedly affected prognosis. In 56% of cases, five or more organ systems were affected, DISCUSSION: Survival in SS is related to the number of affected organ systems. All patients were admitted in critical condition requiring respiratory and inotropic support. Despite strict application of the Surviving Sepsis Campaign (SSC) recommendations and a relatively short time from diagnosis to commencement of adequate treatment, the mortality rate was found to be higher than the European average, but comparable to that from the Polish registry. CONCLUSIONS: Advanced age, male gender and intraperitoneal pathology worsened the prognosis in SS. Mortality was directly related to the number of organ systems involved, and the number of coexistent diseases. An interdisciplinary approach during diagnosis and a reduced time to the start of intensive treatment are essential for survival. Ready access to updated databases on SS enables regular reviews of the results of treatment and improvement of algorithms.

[The clinical spectrum of connective tissue diseases - a single intensive care experience]. / Analiza przypadków ukladowych chorób tkanki lacznej leczonych w oddziale anestezjologii i intensywnej terapii.

BACKGROUND: Systemic connective tissue diseases are relatively rare disorders of unknown origin, possibly related to autoimmunity. In the retrospective study, we analysed the records of nine patients suffering from connective tissue disorders who were treated during a two-year period in an intensive therapy unit. METHODS: Hospital medical records, observational charts and all other available medical documents were analysed. RESULTS: The clinical courses of 9 patients were studied. They included 4 with scleroderma, 3 with systemic lupus erythematosus, and 2 with inflammatory myopathy. They were admitted to the ITU because of sepsis and/or pneumonia, pulmonary haemorrhage, or cardiovascular failure. Three patients (2 with systemic sclerosis, 1 with systemic lupus erythematosus) died. CONCLUSIONS: A multidisciplinary approach to treatment is a key factor in the successful management of patients with rare diseases, such as connective tissue pathologies. Frequent infections with respiratory and/or circulatory complications are the most common causes of severe morbidity in these patients.

Severe fungal infections in intensive therapy.

BACKGROUND: Identification of pathogens in severe fungal infections, by positive cultures, is usually difficult, delays appropriate therapy, and impairs treatment. Despite progress in biologic sciences, the diagnosis of candidiasis still poses a challenge. Early symptoms are not specific, and cultures are usually negative. Molecular methods are rarely used in clinical practice. Common empiric therapy of suspected fungal infection is based on examination, history, and analysis of risk factors. The aim of the study was to analyse fungal infections in ITU and to find factors which may help in their recognition. METHODS: In this retrospective study, the medical histories of ITU patients were analysed. Patients were divided into two groups: I - suspected and II - confirmed, fungal infections. The factors considered were: age, gender, suspected source of fungal infection, co-existing bacterial infection, Candida Score, laboratory tests taken on the day of fungal infection diagnosis (leukocyte count, platelets, and CRP), duration of hospitalisation, declarations of infection from departments, and results of treatment. RESULTS: Statistically significant differences between the groups were found in Candida Scores, duration of hospitalisation and departments of infection. The Candida Scores were higher among those patients in whom infections were already suspected. In this group, the duration of hospitalization was shorter, and infections frequently developed during hospitalisation in the ITU. CONCLUSION: The analysis of infections and Candida Scores helped to initiate prompt antifungal therapy and to reduce the duration of hospitalisation. Infection markers that were routinely used in the ITU were not specific, did not allow identification of patients with fungal infection.

[Reporting on data from cardiopulmonary resuscitation]. / Przydatnosc raportów czynnosci resuscytacyjnych w praktyce klinicznej.

BACKGROUND: In-hospital cardiac arrest is still associated with a high mortality rate, due to late recognition of life-threatening processes such as progressive hypotension, or cerebral ischemia.The aim of the study was to analyse some selected parameters influencing early results of in-hospital cardiopulmonary resuscitation. METHODS: We analysed cardiopulmonary resuscitation reports, prepared following in-hospital cardiac arrests, according to the Utstein templates. In each case, resuscitation was performed according to the recent ERC guidelines. RESULTS: Thirty-eight reports were analysed. 16% of cardiac arrests were caused by defibrillation-susceptible cardiac rhythms, and 84% were non-defibrillation-susceptible. Return of spontaneous circulation was achieved in 45% of cases: in 67% of defibrillation-susceptible cardiac rhythm arrests, and 40% of non-defibrillation-susceptible cardiac rhythm situations. CONCLUSION: The mechanism of cardiac arrest determines the early chance of survival in in-hospital cardiac arrest.