A Critical Reassessment of the Kidney Risk Caused by Tetrastarch Products in the Perioperative and Intensive Care Environments.

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship, the AKI-inducing property of 6% HES 130/0.4 or 0.42 should not be considered as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusions: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Additionally, conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review.

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Mediators of Regional Kidney Perfusion during Surgical Pneumo-Peritoneum Creation and the Risk of Acute Kidney Injury-A Review of Basic Physiology.

Acute kidney injury (AKI), especially if recurring, represents a risk factor for future chronic kidney disease. In intensive care units, increased intra-abdominal pressure is well-recognized as a significant contributor to AKI. However, the importance of transiently increased intra-abdominal pressures procedures is less commonly appreciated during laparoscopic surgery, the use of which has rapidly increased over the last few decades. Unlike the well-known autoregulation of the renal cortical circulation, medulla perfusion is modulated via partially independent regulatory mechanisms and strongly impacted by changes in venous and lymphatic pressures. In our review paper, we will provide a comprehensive overview of this evolving topic, covering a broad range from basic pathophysiology up to and including current clinical relevance and examples. Key regulators of oxidative stress such as ischemia-reperfusion injury, the activation of inflammatory response and humoral changes interacting with procedural pneumo-peritoneum formation and AKI risk will be recounted. Moreover, we present an in-depth review of the interaction of pneumo-peritoneum formation with general anesthetic agents and animal models of congestive heart failure. A better understanding of the relationship between pneumo-peritoneum formation and renal perfusion will support basic and clinical research, leading to improved clinical care and collaboration among specialists.

Reinterpreting Renal Hemodynamics: The Importance of Venous Congestion and Effective Organ Perfusion in Acute Kidney Injury.

The significance of effective renal perfusion is relatively underemphasized in the current literature. From a renal standpoint, besides optimizing cardiac output, renal perfusion should be maximized as well. Among the several additional variables of the critically ill, such as intra-abdominal pressure, the presence of venous congestion and elevated central venous pressures, airway pressures generated by mechanical ventilation do affect net renal perfusion. These forces represent both a potential danger and an ongoing opportunity to improve renal outcomes in the critically ill and an opportunity to move beyond the simplified viewpoint of optimizing volume status. Therefore, to optimize nephron-protective therapies, nephrologists and intensive care physicians should be familiar with the concept of net renal perfusion pressure. This review appraises the background literature on renal perfusion pressure, including the initial animal data and historical human studies up to the most current developments in the field, exploring potential avenues to assess and improve renal blood supply.

The value of combined hemodynamic, respiratory and intra-abdominal pressure monitoring in predicting acute kidney injury after major intraabdominal surgeries.

BACKGROUND: The incidence of postoperative acute kidney injury (AKI) is predominantly determined by renal hemodynamics. Beside arterial blood pressure, the role of factors causing a deterioration of venous congestion (intraabdominal pressure, central venous pressure, mechanical ventilation) has emerged. The value of combined hemodynamic, respiratory and intra-abdominal pressure (IAP) monitoring in predicting postoperative acute kidney injury has received only limited exploration to date. METHODS: Data were collected for adult patients admitted after major abdominal surgery at nine Hungarian ICUs. Hemodynamic parameters were compared in AKI vs. no-AKI patients at the time of admission and 48 h thereafter. Regarding ventilatory support, we tested mean airway pressures (Pmean). Effective renal perfusion pressure (RPP) was calculated as MAP-(IAP + CVP + Pmean). The Mann-Whitney U and the chi-square tests were carried out for statistical analysis with forward stepwise logistic regression for AKI as a dependent outcome. RESULTS: A total of 84 patients (34 ventilated) were enrolled in our multicenter observational study. The median values of MAP were above 70 mmHg, IAP not higher than 12 mmHg and CVP not higher than 8 mmHg at all time-points. When we combined those parameters, even those belonging to the 'normal' range with Pmean, we found significant differences between no-AKI and AKI groups only at 12 h after ICU admission (median and IQR: 57 (42-64) vs. 40 (36-52); p < .05). Below it's median (40.7 mmHg) on admission, AKI developed in all patients. If above 40.7 mmHg on admission, they were protected against AKI, but only if it did not decrease within the first 12 h. CONCLUSIONS: Calculated effective RPP with the novel formula MAP-(IAP + CVP + Pmean) may predict the onset of AKI in the surgical ICU with a great sensitivity and specificity. Maintaining effective RPP appears important not only at ICU admission but during the next 12 h, as well. Additional, larger studies are needed to explore therapeutic interventions targeting this parameter.

Renoprotective Postoperative Monitoring: What Is the Best Method for Computing Renal Perfusion Pressure? An Observational, Prospective, Multicentre Study.

BACKGROUND: Low mean arterial pressure (MAP) is a well-known risk factor for postoperative acute kidney injury (AKI), but probably it is not the sole hemodynamic parameter that can influence the development of renal failure. There are data in cardiac patients supporting the role of renal venous congestion in the development of AKI. The aim of our study was to determine a combination of factors best predicting the development of AKI. METHODS: Data were collected prospectively for adult patients admitted after major abdominal surgery to 9 Hungarian intensive care units. Hemodynamic and laboratory parameters were compared in patients with AKI vs. no-AKI at the time of admission. Renal perfusion was computed by different methods from hemodynamic measurements involving MAP, central venous pressure (CVP), intraabdominal pressure (IAP), and mean airway pressures (Pmean). Twelve different, clinically interpretable equations were tested. Statistical evaluation was performed by the Mann-Whitney U test and ROC analysis. RESULTS: Eighty-four patients were enrolled in the study. Renal perfusion pressure was significantly lower in all equations. The equations MAP-IAP-Pmean (1-area under the curve [AUC]: 0.796; likelihood ratio [LR]+: 3.520; LR-: 0.337; p < 0.01), MAP-IAP-CVP-Pmean (1-AUC: 0.794; LR+: 2.743; LR-: 0.282; p < 0.01), and MAP-2 × IAP-CVP-Pmean (1-AUC: 0.791; LR+: 4.321; LR-: 0.262; p < 0.001) showed small to moderate effect on AKI but have better performance than severity score systems (SAPS II [AUC: 0.696; LR+: 3.143, LR-: 0.433; p < 0.01], SOFA [AUC: 0.717; LR+: 2.089; LR-: 0.528; p < 0.001]). CONCLUSION: We found that the best parameter predicting AKI is the MAP-2 × IAP-CVP-Pmean. Further investigation is needed to analyze the role of CVP and Pmean, and to characterize renal venous congestion and tubular pressure more in detail.

Estimation of the severity of breathlessness in the emergency department: a dyspnea score.

BACKGROUND: Dyspnea is a frequent complaint in emergency departments (ED). It has a significant amount of subjective and affective components, therefore the dyspnea scores, based on the patients' rating, can be ambiguous. Our purpose was to develop and validate a simple scoring system to evaluate the severity of dyspnea in emergency care, based on objectively measured parameters. METHODS: We performed a double center, prospective, observational study including 350 patients who were admitted in EDs with dyspnea. We evaluated the patients' subjective feeling about dyspnea and applied our Dyspnea Severity Score (DSS), rating the dyspnea in 7 Dimensions from 0 to 3 points. The DSS was validated using the deterioration of pH, base-excess and lactate levels in the blood gas samples (Objective Classification Scale (OCS) 9 points and 13 points groups). RESULTS: All of the Dimensions correlated closely with the OCS values and with the subjective feeling of the dyspnea. Using multiple linear regression analysis we were able to decrease the numbers of Dimensions from seven to four without causing a significant change in the determination coefficient in any OCS groups. This reduced DSS values (exercise tolerance, cooperation, cyanosis, SpO2 value) showed high sensitivity and specificity to predict the values of OCS groups (the ranges: AUC 0.77-0.99, sensitivity 65-100%, specificity 64-99%). There was a close correlation between the subjective dyspnea scores and the OCS point values (p < 0.001), though the scatter was very large. CONCLUSIONS: A new DSS was validated which score is suitable to compare the severity of dyspnea among different patients and different illnesses. The simplified version of the score (its value ≥7 points without correction factors) can be useful at the triage or in pre-hospital care.

[Prevalence and associated factors of sarcopenia among older adults living in institutions providing long-term care]. / A sarcopenia prevalenciája, valamint az egészség- és életmódbeli tényezokkel való kapcsolata a tartós ellátást nyújtó intézményekben élo idosek körében.

INTRODUCTION: Earlier studies dealing with sarcopenia were conducted among community-living or hospitalized older adults; however, to date, study focusing on older adults living in institutions providing long-term care is lacking. AIM: The aim of this study was to describe the prevalence of sarcopenia and its associations with lifestyle and health factors among older people living in institutions providing long-term care. METHOD: Two hundred five individuals participated in the study. Sarcopenia was diagnosed based on muscle mass, muscle strength and functional performance. The independent variables were functional mobility, protein intake, smoking, current physical activity, and physical activity when middle-aged, multimorbidity, and falls in the previous year. Univariate models and a multivariate model were used to assess associations. RESULTS: In total 73 participants had sarcopenia. Sarcopenia was associated with smoking, multimorbidity, physically active lifestyle when middle aged, and functional mobility. CONCLUSION: This study showed that lifestyle factors and health condition have important roles in the prevalence of sarcopenia. Orv. Hetil., 2016, 157(46), 1847-1853.

Detecting hypovolemia in postoperative patients using a discrete Fourier transform.

In the present paper, an attempt was made to find waveform-derived variables that would be useful for a more precise diagnosis of hypovolemia. In attempting this, arterial blood pressure graphs of 18 hypovolemic postoperative patients were analysed using a discrete Fourier transform. Using a paired samples t-test, the amplitude of the first harmonic (A1) is shown to be significantly higher in normovolemic cases than in hypovolemic ones (p < 0.001). Based on the values of A1, a preliminary study was performed in which an additional group of 14 hypovolemic and 14 normovolemic patients were categorized into hypovolemic and normovolemic groups using logistic regression. The method proved to be successful in identifying hypovolemic patients: the prediction was correct in 80% and wrong only in 20%, indicating that A1 is potentially a useful parameter in detecting hypovolemia.

The effect of functional movement ability on the quality of life after total hip replacement.

AIMS AND OBJECTIVES: To analyse in detail the relationship between the movement and generic health-related quality of life (HRQoL) indicators and the subjective feeling of health of the patients, as well as the objective movement parameters measured by the surgeon and the patient's opinion about the success of the total hip replacement (THR). BACKGROUND: We have only limited information about the effect of mobility function improvement on the HRQoL several years after THR. We have recently found that after THR postoperative health awareness is influenced mainly by cardiovascular diseases, but the effects of the movement parameters on the subsequent feelings of well-being were not examined. DESIGN: Retrospective longitudinal study. METHODS: This study involved 109 patients who had had THR. The patients' health status and objective and subjective mobility function at the time of operation and five years later were evaluated using questionnaires (including EQ-5D and WOMAC scores) and the hospital database. RESULTS: All components of EQ-5D and WOMAC had significantly improved by Year 5 in patients who experienced a complete recovery after the operation, but not the mobility and pain components of EQ-5D for those patients who felt an improvement only in their subjective mobility function. The surgeon-assessed parameters and use of walking aids showed a similar distribution in patients who considered themselves to be healthy or only moderately sick five years after THR. CONCLUSION: Successful THR significantly improves the feeling of well-being and the mobility function of patients even five years after the operation. In individual cases, however, other subjective and objective factors, but not the mobility function, have a major influence on the HRQoL. RELEVANCE TO CLINICAL PRACTICE: Five years after successful THR, nursing care has to focus not only on the further improvement of the mobility but on strengthening the subjective feeling of the patient's well-being and health.

Epidemiology of postoperative acute kidney injury in Hungarian intensive care units: an exploratory analysis.

BACKGROUND: The aim of this study was to evaluate the incidence and outcome of postoperative acute kidney injury (AKI) after major noncardiac surgery in Hungarian intensive care units (ICUs). METHODS: We conducted an analysis of a multicenter survey on the epidemiology of AKI in Hungarian ICUs in respect of surgical interventions. The cohort study consisted of all patients (n = 295) over the age of 18 years who were admitted to ICUs after surgery between 1 October 2009 and 30 November 2009. AKI was defined and classified by the acute kidney injury network (AKIN) criteria. RESULTS: Forty-eight (18.1%) patients had AKI during their ICU stay. By AKIN criteria, 27 (10.2%) patients were in stage 1, 11 (4.2%) patients in stage 2, and 10 (3.8%) patients in stage 3. The overall mortality rate of AKI was 39.6% (AKI 1: 25.9%, AKI 2: 40%, and AKI 3: 54.5%; p < 0.001) and the ICU mortality rate was 33.3% (AKI 1: 18.5%, AKI 2: 10%, and AKI 3: 54.5%; p < 0.001). According to logistic regression analysis, age (OR: 1.048; CI: 1.014-1.082; p = 0.005), vasopressor treatment (OR: 9.751; CI: 8.579-10.923; p < 0.001), sepsis (OR: 10.791; CI: 9.353-12.233; p = 0.001), serum-creatinine peak-concentration (OR: 1.035; CI: 1.021-1.047; p < 0.001), and intra-abdominal surgery (OR: 2.558; CI: 1.75-3.366; p = 0.020) were independent predictors for AKI. CONCLUSIONS: The results of this study confirm that there is a high incidence of AKI following major noncardiac surgery, which is associated with higher ICU and in-hospital mortality.

Cardiovascular diseases and the health-related quality of life after total hip replacement.

AIMS AND OBJECTIVES: To evaluate to what degree total hip replacement, or co-morbidities or their progression, influence the health-related quality of life of patients after the operation. We have looked for an objective method to reflect the severity of cardiovascular diseases and to better characterise the health-related quality of life of patients with total hip replacement. BACKGROUND: The main weakness of the different health-related quality of life methods that are applied to the analysis is the lack of information regarding the contributory role of co-morbidities, especially cardiovascular diseases. DESIGN: Retrospective longitudinal study. METHODS: This study involved 109 patients who had had total hip replacement. The patients' health status - objective and subjective functional performance at the time of operation and five years later - was evaluated using questionnaires (including EQ-5D and Western Ontario and McMaster Universities' Ostoearthritis Index scores) and the hospital database. An Objective Cardiovascular Classification grouping was developed to evaluate the deterioration of cardiovascular diseases. RESULTS: The subjective assessment of the patients' health status at Year 5 revealed highly significant differences between healthy and sick patients in respect of EQ-5D and Objective Cardiovascular Classification but not in the case of the Western Ontario and McMaster Universities' Ostoearthritis Index scores. Evaluating postoperative subjective health awareness, a higher sensitivity and specificity and a significantly better individual-discriminating role was demonstrated in Objective Cardiovascular Classification vs. EQ-5D. CONCLUSION: After successful total hip replacement postoperative health awareness is influenced mainly by existing and developing cardiovascular diseases. It seems to be the case that for patients with significant hypertension, ischaemic heart disease or chronic heart failure, even successful surgery will not improve the patients' overall feeling of health. RELEVANCE TO CLINICAL PRACTICE: Nursing care of patients with total hip replacement, in respect of cardiovascular diseases, can contribute a better health-related quality of life.

Epidemiology of acute kidney injury in Hungarian intensive care units: a multicenter, prospective, observational study.

BACKGROUND: Despite the substantial progress in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise during hospital admissions. We conducted a national, multicenter, prospective, epidemiological survey to evaluate the importance of AKI in intensive care units (ICUs) in Hungary. The objectives of this study were to determine the incidence of AKI in ICU patients; to characterize the differences in aetiology, illness severity and clinical practice; and to determine the influencing factors of the development of AKI and the patients' outcomes. METHODS: We analysed the demographic, morbidity, treatment modality and outcome data of patients (n = 459) admitted to ICUs between October 1st, 2009 and November 30th, 2009 using a prospectively filled in electronic survey form in 7 representative ICUs. RESULTS: The major reason for ICU admission was surgical in 64.3% of patients and medical in the remaining 35.7%. One-hundred-twelve patients (24.4%) had AKI. By AKIN criteria 11.5% had Stage 1, 5.4% had Stage 2 and 7.4% had Stage 3. In 44.0% of patients, AKI was associated with septic shock. Vasopressor treatment, SAPS II score, serum creatinine on ICU admission and sepsis were the independent risk factors for development of any stage of AKI. Among the Stage 3 patients (34) 50% received renal replacement therapy. The overall utilization of intermittent renal replacement therapy was high (64.8%). The overall in-hospital mortality rate of AKI was 49% (55/112). The ICU mortality rate was 39.3% (44/112). The independent risk factors for ICU mortality were age, mechanical ventilation, SOFA score and AKI Stage 3. CONCLUSIONS: For the first time we have established the incidence of AKI using the AKIN criteria in Hungarian ICUs. Results of the present study confirm that AKI has a high incidence and is associated with high ICU and in-hospital mortality.

The diagnosis of hypovolemia using advanced statistical methods.

AIM: Diagnosing hypovolemia is not a trivial task. Hypovolemia itself has several physical signs, but their specificity and sensitivity is limited, even using sophisticated monitoring techniques. However, diagnosing hypovolemia is crucial in critically ill patients to avoid worse outcomes. The aim of this paper is to provide methods for better estimation of the degree of hypovolemia in ill patients. METHODS: The so-called hypovolemic index (HVI) is introduced which classifies the degree of hypovolemia with a number in the interval [0, 1]. Four new methods are presented for the more precise diagnosis of hypovolemia. All methods rely on fuzzy logic. In the first method, clinical thresholds are used in the fuzzy rule system. The second method uses an iterative ROC analysis to determine the thresholds. The third one determines the thresholds using one single ROC analysis ("One step" method). The fourth method uses a genetic algorithm (GA) for the determination of the thresholds. The HVI is calculated using the data of patients from a previous investigation. Each method (except the first one) is tuned on a so called training database. Afterwards, they are carried out on a test database in order to determine the potential of the method. RESULTS: All four methods are capable of differentiating between hypovolemic and normovolemic patients. However, using the first and the second methods, several patients get a HVI of around 0.5, therefore, their degree of hypovolemia is ambiguous. The third and fourth methods deliver a better classification, hypovolemic and normovolemic patients are clearly separated from each other. CONCLUSION: All four novel methods deliver powerful tools for the diagnosis of hypovolemic patients. The degree of the hypovolemic state of each patient can be estimated with a hitherto unattained degree of reliability. Using ROC analysis and GA the estimation can be improved further.

[Role of cardiovascular disorders in quality of life after total hip replacement]. / Cardiovascularis betegségek szerepe csípoízületi endoprotézis beültetése utáni betegségérzet kialakulásában.

UNLABELLED: This cohort, retrospective study, in the Jávorszky Ödön Hospital, Vác, Hungary, involved 109 patients after total hip replacement. METHODS: The applied questionnaires included the EQ-5D health-related quality of life scores, the Western Ontario and McMaster Universities Ostoearthritis Index (WOMAC) scores, the preoperative and the postoperative 5th year health characteristics. The severity of co-morbidities was graded in respect of clinical signs and pharmacological treatment. RESULTS: The WOMAC values significantly improved in the examination period. However - in spite of the changes in EQ-5D -, it had no influence on adherence of feeling sick after total hip replacement. Among the co-morbidities, the cardiovascular diseases had a distinguished role because their prevalence and deterioration showed a close relationship with the subjective health-feeling of the patients. CONCLUSION: According to our study, we have to consider that in case of significant hypertension, ischemic heart diseases or chronic heart failure even the successful surgery will not improve the general sick-feeling of the patients.

Short-term effectiveness of different volume replacement therapies in postoperative hypovolaemic patients.

BACKGROUND AND OBJECTIVE: To examine the kinetics of volume loading with crystalloid and colloid infusions in critically ill patients after major surgery, using the pulse contour cardiac output (PiCCO) monitoring technique. METHODS: This prospective, randomized, multicentre study of 11 ICUs involved 200 mixed postoperative hypovolaemic patients (50 patients per group) in Hungary. Patients received 10 ml kg of lactated Ringer's solution, succinylated gelatin 4% w/v, 130/0.4 hydroxyethyl starch 6% w/v (HES) or human albumin 5% w/v over 30 min. A complete haemodynamic profile was obtained at 30, 45, 60, 90 and 120 min after baseline. The peak haemodynamic effects, the 120 min changes compared with baseline, the area under the curve (AUC) for the haemodynamic parameters over 120 min and the haemodilution effect of the solutions were analysed. The primary outcome was to compare the AUCs and the secondary outcome was to evaluate the haemodynamic changes at 120 min. RESULTS: There were significant differences in the AUCs of the haemodynamic parameters between colloids and lactated Ringer's solution in the cardiac index and global end-diastolic volume index (GEDVI); human albumin vs. lactated Ringer's solution in stroke volume variation (SVV); and succinylated gelatin, HES vs. lactated Ringer's solution in the oxygen delivery index (DO2I). Colloid infusions (mainly HES and human albumin) at 120 min caused significant changes in central venous pressure, cardiac index, GEDVI, SVV, DO2I and central venous oxygen saturation compared with baseline. The haemodilution effect was significantly greater in colloids vs. lactated Ringer's solution. CONCLUSION: In postoperative hypovolaemic patients, lactated Ringer's solution can significantly improve haemodynamics at the end of volume loading, but this effect completely disappears at 120 min. Ten millilitres per kilogram of colloid bolus (especially HES) improved the haemodynamics at 120 min; however, this was by only 5-25% compared with baseline. The colloids caused significantly larger AUCs than lactated Ringer's solution, but only in the cardiac index, GEDVI and DO2I, plus human albumin in the SVV.

Precision of transpulmonary thermodilution: how many measurements are necessary?

BACKGROUND AND OBJECTIVES: To analyse the precision of transpulmonary thermodilution from the PiCCO technique (Pulsion Medical System, Munich, Germany) in everyday intensive care practice in order to ascertain the minimum number of measurements necessary for scientific precision. METHODS: An observational study in the medical-surgical ICU of a teaching hospital was performed. Thirty consecutive patients from a mixed intensive care population using the PiCCO haemodynamic monitor were included. Five thermodilution measurements were repeated at 2 min intervals. The variability of the cardiac index and the global end-diastolic volume index was analysed with respect to the five consecutive measurements and the mean of the first two, first three, first four and all five measurements. RESULTS: There was similar distribution among the different measurements and means. The variability of the cardiac index and global end-diastolic volume index, represented by the standard error of means, the coefficient of errors and the confidence intervals, revealed a similar precision in separate measurements and in the different averaging techniques. The coefficient of errors was less than 5% even when calculating the mean of the first two measurements, meeting the criterion of scientific precision, and including patients with arrhythmia and varying blood pressure. CONCLUSION: Calculating the mean of two good-quality transpulmonary thermodilution measurements is equivalent to the other averaging techniques (three to five measurements) for the cardiac index and global end-diastolic volume index. Any further repeated measurements may be unnecessary and may contribute to volume overloading.

[Principles of intensive care in severe acute pancreatitis in 2008]. / Az akut súlyos pancreatitis intenzív terápiás kezelési elvei 2008-ban.

Acute pancreatitis is a dynamic, often progressive disease; 14-20% require intensive care in its severe form due to multiorgan dysfunction and/or failure. This review was created using systematic literature review of articles published on this subject in the last 5 years. The outcome of severe acute pancreatitis is determined by the inflammatory response and multiorgan dysfunction - the prognostic scores (Acute Physiology and Chronic Health Evaluation, Glasgow Prognostic Index, Sepsis-related Organ Failure Assessment, Multi Organ Dysfunction Syndrome Scale, Ranson Scale) can be used to determine outcome. Clinical signs (age, coexisting diseases, confusion, obesity) and biochemistry values (serum amylase, lipase, C-reactive protein, procalcitonin, creatinine, urea, calcium) have important prognostic roles as well. Early organ failure increases the risk of late abdominal complications and mortality. Intensive care can provide appropriate multi-function patient monitoring which helps in early recognition of complications and appropriate target-controlled treatment. Treatment of severe acute pancreatitis aims at reducing systemic inflammatory response and multiorgan dysfunction and, on the other side, at increasing the anti-inflammatory response. Oral starvation for 24-48 hours is effective in reducing the exocrine activity of the pancreas; the efficacy of protease inhibitors is questionable. Early intravascular volume resuscitation and stable haemodynamics improve microcirculation. Early oxygen therapy and mechanical ventilation provide adequate oxygenation. Electrolyte and acid-base control can be as important as tight glucose control. Adequate pain relief can be achieved by thoracic epidural catheterization. Early enteral nutrition with immunonutrition should be used. There is evidence that affecting the coagulation cascade by activated protein C can play a role in reducing the inflammatory response. The complex therapy of acute pancreatitis includes appropriate antibiotics, thrombo-embolic prophylaxis and in certain cases plasmapheresis and/or haemofiltration. Reducing intraabdominal pressure may be necessary in the acute phase. Intensive care multidisciplinary teamwork can reduce the mortality of severe acute pancreatitis from 30% to 10%.

Intramucosal pH monitoring during liver transplantation.

PURPOSE: To apply tonometry as a quick estimation of the early liver graft function. PATIENTS AND METHODS: Forty-five liver-transplanted patients were examined. Data were collected prospectively and analysed retrospectively. According to the early graft function, patients were classified into two groups: in group 1 (n = 28) adequate graft function, in group 2 (n = 17) deteriorated graft function was detected in the early post-operative period. Complete conventional and volumetric haemodynamic monitoring and intramucosal pH (pHi), regional CO2 tension (PrCO2) measurements were performed during surgery and until the 36 hours post-operatively. RESULTS: In group 2 the packed blood cell, fresh frozen plasma consumption intraoperatively, and the time of hepatectomy were significantly higher; ICU treatment days, respiration time was longer and mortality rate was higher. Almost the whole examination period pHi was mostly below 7.3 and PrCO2 above 50 mmHg in group 2. There were significant differences in pHi between the groups from the preparation phase until the 24th post-operative hour. In group 2, there were significantly lower values in cardiac output in the whole examination period and in the mean arterial pressure values in the revascularization phase. In group 1, the oxygen delivery values were significantly higher in the preparation phase and oxygen consumption values after revascularization phase. With regression analysis there were no significant correlations between pHi, PrCO2 and global haemodynamic parameters. CONCLUSION: Regional parameters were completely different from global haemodynamic parameters, therefore pHi and PrCO2 can be a good indicator of the early liver graft dysfunction.

Analysis of systemic and regional procalcitonin serum levels during liver transplantation.

Elevated procalcitonin (PCT) levels are observed early after orthotopic liver transplantation (OLTx). The aim of this study was to evaluate the changes in systemic and regional PCT serum levels from the time of organ harvesting until the early postoperative phase of OLTx ( n=28) and to investigate the prognostic suitability of postoperative changes in PCT level for the outcome of OLTx ( n=61). Only in seven of 28 donors were higher PCT levels found (0.84+/-0.43 ng/ml). During organ preservation, hepatectomy, and in the anhepatic phase, the PCT levels were in the normal range; in 11 of 28 cases hepatic vein PCT levels were higher during graft flush with own blood than the systemic or portal vein samples at the same time (1.27+/-0.43 ng/ml vs 0.16+/-0.26 ng/ml and 0.23+/-0.15 ng/ml, respectively, P<0.02). The elevation of PCT levels began immediately after graft reperfusion (1.04+/-0.77 ng/ml vs 0.27+/-0.22 ng/ml, P<0.001), and the levels at postoperative day 2 were significantly higher in the case of postoperative complications (30.6+/-19.6 ng/ml vs 4.8+/-3.6 ng/ml, P<0.001).