Danger of bacterial translocation for a surgical patient.

Intestinal barrier disorder manifestation occurs in connection with surgery in conditions of shock ischemia-reperfusion of the intestine or deterioration of an already damaged barrier due to chronic disease. The result is infectious complications caused by the transport of pathogens through the venous blood, most often postoperative pneumonia and sepsis. However, a more frequent manifestation is the intensification of the postoperative systemic inflammatory response through the lymphatic transport of toxic substances, inanimate antigens and cytokines through the lymphatic system of the splanchnic area (gut-lymph axis). The problem can affect up to half of patients with abdominal surgery. Preventive measures consist of strengthening the intestinal barrier before surgery and alleviating the loss of the intestinal barrier in the perioperative period. In the treatment of infectious complications, an early recognition indication for the therapeutic administration of antibiotics based on preoperative microbial screening of patients at risk may help.

The bioimpedance spectroscopy as useful tool for measuring the fluid excess and fluid management in severe polytrauma patients.

Although the fluid therapy plays a fundamental role in the management of polytrauma patients (PP), a tool which could determine it appropriately is still lacking. The aim of this study was to evaluate the application of a bioimpedance spectroscopy (BIS) for body fluids volume and distribution monitoring in these patients. This prospective, observational study was performed on 25 severe PP and 25 healthy subjects. The body fluids composition was repeatedly assessed using BIS between days 3 to 11 of intensive care unit stay while the impact of fluid intake and balance was evaluated. Fluid intake correlated significantly with fluid excess (FE) in edemas, and their values were significantly higher in comparison with the control group. FE was strongly associated with cumulative fluid balance (p<0.0001; r=0.719). Furthermore, this parameter was associated with the entire duration of mechanical ventilation (p=0.001, r=0.791) independently of injury severity score. In conclusion, BIS measured FE could be useful in PP who already achieved negative fluid balance in prevention the risk of repeated hypovolemia through inappropriate fluid restriction. What is more, measured FE has a certain prognostic value. Further studies are required to confirm BIS as a potential instrument for the improvement of PP outcome.

Fasciitis necrotisans - duplicitas casuum.

Necrotizing fasciitis is a dangerous bacterial infectious disease that is not commonplace in Czech society. On the other hand, neither is it so rare that the majority of surgeons should not come across it occasionally. In the early stages, pathological changes in fascia, subcutaneous tissue and even skin may run an inconspicuous course. However, this can rapidly deteriorate into shock and sepsis which may lead to multi-organ failure and an imminent life-threatening condition. The fatality rate of necrotizing fasciitis among high-risk groups (e.g. diabetics, patients who are immuno-compromised, obese and/or elderly, malnourished, or with a history of drug use), is particularly steep, reaching as high as 73%. Treatment for this condition consists of early, radical surgical intervention in conjunction with targeted antibiotherapy. Complex resuscitative and intensive care, including rehabilitation, are standard components of post-surgical management. Use of hyperbaric oxygen therapy, if such an opportunity exists, is also recommended. Interdisciplinary collaboration is a vital prerequisite for successful treatment. This article describes two case-studies of necrotizing fasciitis that occurred in men of similar age during a three-year period. Both patients presented with very similar and complicated disease courses, and both were successfully treated by the same interdisciplinary team comprised of clinicians from various specialized departments. Key words: necrotizing fasciitis - radical necrectomy - antibiotherapy - hyperbaric oxygen therapy - complex resuscitative and intensive care.

Antioxidant defense system in familial hypercholesterolemia and the effects of lipoprotein apheresis.

Oxidative stress is thought to play an important role in the pathogenesis of disorders associated with atherosclerosis. Alpha-tocopherol is considered to be an effective lipophilic antioxidant, which protects lipid membranes against peroxidation and thus prevents cell damage by reaction with free radicals. However, measurement of alpha-tocopherol concentration in serum does not reflect the content of α-tocopherol in membranes whereas erythrocyte alpha-tocopherol may be good indicator of antioxidative status. Therefore a simple isocratic reversed phase HPLC method has been developed and validated for the determination of alpha-tocopherol in human erythrocytes in a clinical setting. The content of alpha-tocopherol in human erythrocyte membrane and lipoperoxidation were studied in patients with severe hypercholesterolemia treated by lipoprotein apheresis. The group of hypercholesterolemic patients (n = 14) treated by lipoprotein apheresis was compared to healthy adult normolipidemic controls. After lipoprotein apheresis, the content of in membrane alpha-tocopherol did not change significantly despite decreased tocopherol in serum and lipoprotein fractions. We observed significantly decreased lipoperoxidation as revealed by serum TBARS, representing end products of lipid peroxidation, which increased from third day afterwards and remained significantly higher in comparison to controls until the next LDL-apheresis. We conclude that aggressive lipid lowering procedure with lipoprotein apheresis was associated with favorable transient decrease of lipoperoxidation. Simultaneously the cell membrane bound antioxidative defense mechanisms as reflected by the content of alpha-tocopherol in human erythrocyte membrane where not depressed in spite of its decreased plasma lipid carrier. Another variables involved remain to be investigated.

Lipoprotein apheresis in the treatment of dyslipidaemia - the Czech Republic experience.

In 1984, we started using therapeutic plasmapheresis (plasma exchange) as a method of extracorporeal lipoprotein elimination for the treatment of hypercholesterolemic patients. We evaluated the results of long-term therapy in 14 patients, 8 men and 6 women. The average age was 55.6+/-13.2 (range 28-70), median 59.5 years. 14 patients were diagnosed with familial hypercholesterolemia (FH): 5 homozygous, 9 heterozygous. Ten patients in the group were treated using immunoadsorption lipoprotein apheresis and 4 using hemorheopheresis. Immunoapheretic interventions decreased LDL-cholesterol (82+/-1 %), ApoB (73+/-13 %) and even Lp(a) by 82+/-19 %, respectively. Selected non-invasive methods are important for long-term and repeated follow-up. Carotid intima-media thickness showed improvement or stagnation in 75 % of the patients. Biomarkers of endothelial dysfunction such as endoglin (in the control group: 3.85+/-1.25 microg/l, in lipoprotein apheresis-treated hypercholesterolemic individuals 5.74+/-1.47 microg/l), CD40 ligand (before lipoprotein apheresis: 6498+/-2529 ng/l, after lipoprotein apheresis: 4057+/-2560 ng/l) and neopterin (before lipoprotein apheresis: 5.7+/-1.1 nmol/l, after lipoprotein apheresis: 5.5+/-1.3 nmol/l) related to the course of atherosclerosis, but did not reflect the actual activity of the disease nor facilitate the prediction or planning of therapy. Hemorheopheresis may improve blood flow in microcirculation in familial hypercholesterolemia and also in some other microcirculation disorders via significantly decreased activity of thrombomodulin (p<0.0001), tissue factor (p<0.0001), aggregation of thrombocytes (p<0.0001) and plasma and whole blood viscosity (p<0.0001). In conclusion, lipoprotein apheresis and hemorheopheresis substantially lowered LDL-cholesterol in severe hypercholesterolemia. Our experience with long-term therapy also shows good tolerance and a small number of complications (6.26 % non-serious clinical complications).

[Secondary peritonitis and volume therapy - single-site retrospective analysis]. / Sekundární peritonitida a potreba tekutinové lécby - retrospektivní analýza jednoho pracoviste.

INTRODUCTION: Secondary peritonitis is a typical surgical intensive care situation. Leakage of fluid into the interstitial space and peritoneal cavity requires adequate fluid resuscitation to optimize the hemodynamic stability. The aim of the study is to present specific volumes of fluid transfer in situations of acute peritonitis based on a single-site retrospective analysis of volume therapy in patients with this condition. METHODS: Retrospective analysis of patients with secondary peritonitis treated at ICU-1 of the Surgical Department of the University Hospital in Hradec Kralove between 20132016. Volume therapy was provided using balanced crystalloids and was monitored based on dynamic hemodynamic indicators (variations of the pulse waveform, response to fluid challenge, physical examination). Fluid balance was managed by intake and output measurements and by estimating immeasurable losses. RESULTS: We evaluated the set of 139 patients with severe secondary peritonitis according to the Mannheim Peritonitis Index (MPI) 27.9 and predicted lethality 26%. The lethality actual was 24%. Hemodynamic stabilization was associated with the mean cumulative positive fluid balance of 8643 ml, which peaked after 1.83 day from admission. The average length of ICU stay was 8 days. Blood pressure support with norepinephrine was necessary in 42% of patients and lasted the mean of 32 hours. None of the patients was on dialysis; in two cases, kidney failure occurred in a situation of generalized cancer and intractable vascular ileus. CONCLUSION: Peritonitis leads to significant leakage of fluids into the third space, and in surgery, it is one of conditions characterized by the highest need of fluid therapy in the resuscitation phase of sepsis and septic shock. The risk of underestimating fluid therapy is high in practice.Key words: peritonitis septic shock - fluid optimization positive fluid balance.

[Skin and soft tissue infections (SSTIs)]. / Infekce kuze a mekkých tkání.

UNLABELLED: Skin and Soft Tissue Infections (SSTIs) encompass a wide spectrum of inflammatory diseases of the skin, subcutis, fascia and muscles. Recent national trends indicate increasing rates of patients treated for these diagnoses at outpatient surgical department, but also of patients hospitalized with severe forms of SSTIs. Up to 90% fatality rates are reported in the literature for the most severe forms, resulting from underestimation of initial symptoms and therefore delayed onset of radical therapy only the phase of septic shock. The paper provides an interdisciplinary review of essential principles of the diagnosis and therapy of SSTIs, reflecting present knowledge supported by evidence-based medicine. KEY WORDS: skin and soft tissue infections - SSTIs - necrotizing fasciitis - diagnosis - therapy.

[Personalised antibiotic therapy in a surgical intensive care unit overview of current knowledge and the results of an observational kinetic study]. / Personalizovaná antibiotická terapie na chirurgické jednotce intenzivní péce prehled soucasných znalostí a výsledky observacní kinetické studie.

INTRODUCTION: The current efforts of intensivists focused on individual antibiotic treatment in patients suffering from sepsis has inspired us to conduct an open prospective clinical study to assess the relationship between body fluid retention (>10 L/24 hours) and the efficiency of hydrophilic time-dependent antibiotics used in critically ill patients. Polytrauma and abdominal catastrophes are the most frequent causes of systemic inflammatory response syndrome (SIRS). Consequent body liquid retention is taken for a pathophysiological covariate modifying the pharmacokinetics (PK) and pharmacodynamics (PD) of hydrophilic time-dependent antibiotics (betalactams and carbapenems). Not only body fluid retention but also changes in renal clearance are thought to be responsible for failure in PK/PD target attainment necessary for effective antimicrobial activity. To describe the importance of the pathophysiological covariates for the individual kinetic variables of a representative antibiotic (piperacillin) is the primary goal of this kinetic observational study. MATERIAL AND METHODS: Three patients with polytrauma and SIRS admitted at the ICU of the Surgical Department, Teaching Hospital Hradec Králové, whose condition was characterized by cumulative body fluid retention (>10 L), were eligible for enrolment. As per standard hospital protocol, the patients were administered with 4 g of piperacillin in combination with tazobactam 0.5 g intravenously by 1-hour (h) infusion every 8 h. A series of blood samples were taken 1, 2.5, and 5 h after the termination of the infusion. Urine was collected over each dosing interval and for 24 h. Piperacillin was detected using a previously validated HPLC method. Individual pharmacokinetic variables were estimated using non-compartmental pharmacokinetic analysis. Cumulative body fluid retention was calculated as the difference between fluid intake and output. Creatinine clearance (Cl) was used for renal function evaluation. PK/PD target attainment was analysed according to Carlier (2013). RESULTS: In three patients with polytrauma and SIRS, great interindividual and intraindividual differences in extravascular volume expansion, i.e. cumulative body fluid retention 2030 L and changes in renal function, were recorded. In 2/3 patients these pathophysiological changes as well as the clinical interventions administered resulted in augmented piperacillin clearance and an increase in distribution volume (Vd) (>20 L) with a maximum at Day 28 after initiation of therapy. In such patients treated with a standard dose of piperacillin, only minimum PK/PD target attainment (50% Ft >MIC) was obtained. In contrast, a patient suffering from renal dysfunction attained both minimum (50% ft >MIC) and maximum PK/PD target (100% ft >MIC). CONCLUSIONS: In three critically ill patients with polytrauma and SIRS, pathophysiological changes (covariates) had a profound effect on the key determinants of the pharmacokinetics (Cl and Vd), resulting in significant intraindividual variability in pharmacodynamic /pharmacokinetic target attainment necessary for therapeutic time-dependent antibacterial activity of piperacillin. Consequently, patients with augmented clearance of piperacillin may be at risk for treatment failure, and/or bacterial resistance without dose up-titration. A subsequent clinical study will be conducted to describe personalised kinetically guided antibiotic therapy.

[Basic principles of diagnosis and treatment of secondary peritonitis - recommendations of experts with the support of SIS]. / Základní principy diagnostiky a lécby sekundární peritonitidy - doporucení odborníku s podporou SIS.

Secondary peritonitis is the most common cause of inflammatory acute abdomen treated at general surgery departments. Only early and correct diagnosis may improve the prognosis of these patients. The authors compiled an interdisciplinary review of the basic principles of diagnosis and treatment of secondary peritonitis, which reflects current findings supported by evidence-based medicine. The work is based on published international literature but also shares opinions and experiences of the selected specialists. The presented work in its extent is not meant to substitute an in-depth study of the issue, but to allow a basic and quick review of the topic.

[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.

[When a surgical patient needs parenteral nutrition]. / Kdy potrebuje chirurgický pacient parenterální výzivu.

INTRODUCTION: Some recent studies suggest that the blanket use of parenteral nutrition may be harmful in the event of short-term starvation due to acute illness. Utilization of endogenous substrate resources which are mobilized anyway due to acute illness or operation allows the organism to survive and recover from acute damage without nutritional support. Modern, less invasive procedures in surgery, good preoperative nutritional status and early recovery of food intake after surgery on the one hand and the side effects and risks of artificial nutrition on the other hand raise the question whether surgery in general still needs parenteral nutrition. Even on the basis of modern knowledge we cannot explain why, in standard administration of parenteral nutrition, there is a higher incidence of postoperative complications. Is parenteral nutrition directly toxic or useless, or are we just unable to avoid the side effects of improper application? METHODS: In most cases, the body has protein and energy storage large enough to heal the wound and anastomosis. But the hypometabolic status of the starved organism requires more time for the healing process, and ubiquitous protein catabolism due to postoperative inflammation can exhaust the immune defences of the body. The importance of nutritional support and metabolic optimization is shifting to preoperative strengthening. Artificial feeding is used to stimulate protein synthesis which is necessary for healing on the one hand, and to replenish protein and energy reserves on the other. Protracted catabolism is a risk factor for prolonged immunosuppression and fatal loss of endogenous protein. CONCLUSION: Malnutrition is a significant cause of postoperative complications. In planned operations, artificial nutritional support is targeted at patients with low protein synthesis (persons with low food intake lasting several days), patients who are obviously malnourished, those with expected long starvation (5-7 days), and patients with high catabolism. Protein synthesis accelerates in a few days after nutritional support has been started. The nutritional indicators improve in a few weeks after nutrition has been initiated and the risk of postoperative complications due to malnutrition persists up to several months after surgery.

[Disturbance of synthesis of cholesterol and its precursors in clinically serious conditions]. / Porucha syntézy cholesterolu a jeho prekurzoru u klinicky závazných stavu.

OBJECTIVE: The aim of the study was to elucidate the role and importance of hypocholesterolemia in clinically serious conditions. It was a monocentric, prospective clinical study. MATERIAL AND METHODS: Two groups of patients were recruited to the study--one group were patients with coronary heart disease (CHD), who underwent miniinvasive cardiosurgical operation without extracorporeal circulatio (n = 17) and one group of patients, who sustain polytrauma (n = 19). Thirty six patients were recruited into the study. We performed the determination of sterols (total cholesterol, HDL-cholesterol, LDL-cholesterol, triacylglycerols), and their precursors (beta-sitosterol, campesterol, lathosterol, skvalen), interleukin IL-6 and cortisol in the blood serum. The short version of ACTH stimulation test was performed. The oxidative burst of granulocytes was evaluated. The blood samples were taken on the day of admission, the first, the fourth and the eighth post-operative and post-traumatic day. RESULTS: There was a significant decline of total cholesterol (TC) and LDL-cholesterol level with full recovery during observed period. There was a decline of cholesterol synthesis (lathosterol and lathosterol/cholesterol ratio) together with a decline of total cholesterol. There was a significantly negative correlation between IL-6 level and total cholesterol. Despite no confirmation of disturbance of adrenal function, there was a significantly positive correlation between lathosterol/cholesterol ratio (a de novo cholesterol synthesis marker) and cortisol level after the ACTH stimulation test. There was a significant breakdown of bactericidal function of granulocytes along with a decline of cholesterol level. CONCLUSION: There was decline of endogenous cholesterol synthesis in clinically serious conditions. The cholesterol synthesis rate is negatively influenced by IL-6 level. The rate of endogenous cholesterol synthesis positively correlated with cortisol production by the adrenals and with bactericidal function of granulocytes.

[Truncus coeliacus stenosis in duodenopancreatectomy]. / Stenóza truncus coeliacus pri duodenopankreatektomii.

INTRODUCTION: Patients with celiac axis stenosis are asymptomatic due to the rich collateral blood supply through superior mesenteric artery. Ligating and dividing gastroduodenal artery during pancreatoduodenectomy can cause ischemic threat especially to liver, less frequently stomach and spleen, or failure of anastomoses. CASE REPORT: The authors present a case of 27-year-old female who underwent duodenopancreatectomy for pseudopapillary tumour of the head of pancreas. Celiac axis stenosis was found peroperatively and proven during angiography. Although an attempt of endovascular dilatation of celiac axis was unsuccessful, blood supply to the liver was sufficient and therefore we did not perform any other intervention to improve blood flow to the liver. Postoperative course was uneventful. DISCUSSION: Celiac axis stenosis can be caused by tumour infiltration or lymphadenopathy in malignant disease, atherosclerosis or compression of the median arcuate ligament. The stenosis can be managed by endovascular treatment or arterial reconstruction. In conclusion the authors propose a management algorithm to prevent the consequences of celiac axis stenosis.

[Case report: fat embolism syndrome--grave handicap after traumatic long-bones fractures]. / Syndrom tukové embolie--prehled problematiky a kazuistika: závazný prubeh po traumatu dlouhých kostí.

Embolism of fat and bone marrow tissue is quite often due to bone fractures but it is seldom with signs of systemic involvement as a fat embolism syndrome. The main forming factor is late stabilization of fractures and hypovolemia too. Clinical image of fat embolism syndrome results from lung and systemic microembolism which leads to activation of inflammatory and thrombogenic cascades. We present a case report of a 24-year-old male after bike accident in low speed suffering from isolated thighbone fracture--osteosynthesis was applied in 6 hours after injury. The very first day the organ failure and coma with negative CT occurred, then ARDS, petechiae into the skin of chest and conjunctiva, also embolic closure of a. centralis retinae. Treatment interventions included anticoagulation, steroids, artificial ventilation for 17 days. After 3 weeks from injury he was still unconscious (with GCS 10) so that we tried a hyperbaric oxygen therapy. The patient regained consciousness after 3 months after injury. One year later he is able to walk alone, he has no visual failure, but he is still quadruspastic although able to manipulate with a mobile phone. We discuss diagnostic criteria and treatment. We also point out need of volumetherapy in prevention of fat embolism syndrome--this was underrated here because of primary missed out diagnose of co-existing tibia fracture at the same time (this was stabilised 18 hours after injury).

Extracorporeal LDL cholesterol elimination (25 years of experience in CZ).

In the Czech Republic the therapy of severe familial hypercholesterolemia (FH) by extracorporeal elimination using LDL-apheresis (immunoadsorption) and hemorheopheresis is concentrated into one center. The authors evaluate the long-term therapy (3-12 years, median 7,25) in 12 patients with FH - 3 homozygous, 9 heterozygous; Fredrickson type IIa, IIb (treated: 9 by LDL-apheresis and 3 by hemorheopheresis). Immunoapheretic interventions decrease LDL-cholesterol, ApoB and even Lp(a) by about 82 +/- 1; 73 +/- 13; 82 +/- 19 %, respectively. Selected non-invasive methods are important for a long-term and repeated follow-up. Carotid intima-media thickness showed improvement or stagnation in 75% of the patients. The level of some adhesive molecules, cytokines, endoglin and some coagulation functions were measured, but no universally accepted biomarkers informing of the actual activity of the disease were found to predict and plan the therapy. A program for procedure planning with the use of Microsoft® Excel for Windows® was developed. In summary, LDL-apheresis and hemorheopheresis substantially lower LDL-cholesterol in FH. Our experience with long-term therapy also shows good tolerance and a small number of complications (5,6% of clinically irrelevant side-effects). Hemorheopheresis may improve blood flow in microcirculation in familial hypercholesterolemia and also in some other disorders of microcirculation.

[Radiofrequency-assisted liver resection. Analysis of a group of consecutive patients treated at a single centre]. / Radiofrekvencne asistovaná resekce jater. Analýza skupiny pacientu operovaných v jednom centru.

AIM: To evaluate clinical experience with radiofrequency (RF)-assisted liver resection in patients with metastatic liver disease. METHODS: A group of consecutive patients who underwent liver resection using the RF-assisted technique were prospectively followed. RESULTS: Between July 2005 and September 2006, 65 liver resections were performed, among these, 40 procedures were performed using the RF technique for metastatic disease. The mean operative time was 141 (range 64-233) minutes, and the mean duration of RF parenchyma coagulation of the resected surface was 17.5 (range 2-32.5) minutes; mean 10 (range 9-12) minutes in the case of right hemihepatectomy. Blood transfusions associated with the operation were administered in 3 (7.5%) patients. The mean number of transfusion units of red blood cells administered was 0.2 (range 0-3). Liver resection was complicated by biliary fistula in 1 patient (2.5%) after mesohepatectomy, hepatic abscess was observed in 1 patient (2.5%) and subdiaphragmatic abscess was observed in 2 patients (5%). CONCLUSION: This study indicates that RF-assisted resection may have a benefit in decreasing perioperative blood loss and the volume of transfused blood, without a higher incidence of wound and infectious complications. An increased incidence of pleural effusions that required evacuation was noted.

Fulminant course of metastatic liposarcoma after delivery--case report.

Abdominal liposarcoma is a rare tumor of uncertain prognosis. Radical surgery is possible in about two-thirds of the patients, and the prognosis of patients with inoperable tumors is dismal. Only a few cases of liposarcoma complicating pregnancy have been documented. We report a case of a patient who was diagnosed with metastatic abdominal liposarcoma during the third trimester of the pregnancy. After induced vaginal delivery, palliative surgery was performed and one cycle of systemic combination chemotherapy was administered. Despite the multimodality treatment the patient died of progressive disease within one month after diagnosis. Autopsy revealed high-grade pleomorphic liposarcoma arising from the retroperitoneum with liver and lung metastases.

[Preparation of patients for operation with per-oral intake on the day of the planned surgery]. / Príprava k operaci s perorálním príjmem v den plánovane operace.

INTRODUCTION: The clinical studies carried out leads to the hypothesis that the starvation of patients for several hours prior to a surgical procedure has a negative influence on the internal metabolic environment of a patient. It also has an impact on the psychosomatic disposition of the patient's physiology of metabolic processes and the proper functioning of vital organs and systems. This hypothesis was already stated by doctors specialized in Intensive Care Units in other European countries. In the frame of methodology, ERAS (enhancement recovery after surgery) also known as fast track, solves this problem not only on the level of clinical studies but also clinical practice. METHODOLOGY AND GROUP OF PATIENTS: The group of patients selected had been surgically treated for disease of the colon (both benign and malignant) and were divided into 3 groups: A--basically starving from mid-night of the day of operation, B--patients secured the night before the operation and on the day of the operation by a parenteral intake of 10% glucose solution with minerals, C--patients drinking a special drink, consisting basically of sugars (mainly maltodextrin) mixed in with minerals, the evening before the operation and on the day of the operation. Patients used in this study were required to fulfill several criteria to be included into the study: these criteria consisted of a co-morbidity of ASA 1-2, weight 60-90 kg, age 35-75 years, operating time of the procedure on the colon of 120 +/- 30 min. without complications. These patients also had not been given any transfusions of red blood cells or blood derivatives during or after the surgery (or during the time of hospitalization etc). The selected biochemical markers, muscular power, some cardial function, and subjective patients feelings were monitored in all patients during perioperative period. The basic statistical methods were used for evaluation of current results. RESULTS: The monitored parameters of the internal environment showed that the dynamics of the basic minerals had been roughly the same. The same scenario was found with serous concentrations of glucose, CRP, and albumin. In the group of patients given the sugar solution, there was a relative decrease in the serous concentration of insulin post-operatively (which is related to a lower insulin resistance) and serous concentration of myoglobin and creatin kinase. At the start of anesthesia, patient's stomachs contained the lowest volume of residual liquid with a low pH in the group that was drinking the fluid on the day of the operation. The results of the measurements of muscular power (force) and echocardiograph have not been elaborated in detail so far. Unpleasant feelings in patients on the day of the operation like thirst, hunger, nervousness, fear, etc. were mainly reduced in the group of drinking patients. CONCLUSION: Till date the findings documented by monitored indicators may prove that the implementation of per-oral intake on the day of an surgery will benefit and improve the quality of care of surgically treated patients and increase the number of successful operations.

[Acute pancreatitis]. / Akutní pankreatitida.

Acute pancreatitis is an insidious inflammatory disease of the pancreas with its serious form leading to mortality in 20 to 30% of patients. Seemingly good clinical state at the onset of the disease is the cause of underestimation of resuscitation care in first hours of the disease. Whereas a basic prevention of the development of multiorgan dysfunction are an early re-establishing of the microcirculation and supranormal hemodynamic values. Making a differential diagnosis of the mild and the severe form of pancreatitis is possible after several days of intensive resuscitation care. Treatment of complications of acute pancreatitis, especially a long-term inflammatory process in retroperitoneum, require a patient and sometimes several month lasting intensive approach and interdisciplinary co-operation. Too early removal of drainage from the area of a necrotic gland or suppuration in retroperitoneum can be fatal to the patient.

[Cholestatic icterus during parenteral nutrition and the therapeutic effect of enteral feeding--case report]. / Cholestatický ikterus na parenterální výzive a lécebný vliv enterální aplikace--kazuistika.

An acute operation was made on a 56-year woman for inflammatory perforation of colon. A series of repeated operations followed due to relapsing iatrogenic intestinal fistula and peritonitis. From the day 70 the patient was treated at the Intensive Metabolic Care Unit of the Gerontological and Metabolic Clinic of Faculty Hospital in Hradec Králové. Having cured the septic shock the authors prepared the patient to a reconstruction operation on alimentary tract by administering parenteral nutrition, treating the wounds and by motion rehabilitation. From day 150 on the patient was treated with low doses of enteral nutrition into the segment of intestine between the fistulas, in connection with the subsequent decrease of two-month lasting hyperbilirubinemia of 200-260 mumol/l. A successful reconstruction of the alimentary tract was performed on the day 205 of the treatment with the time lapse of 146 days after the last surgical intervention. A three-fold anastomosis on small intestine and a resection of the fistula on the transversal colon was made. The post-operation fistula was healed-up conservatively, while the parenteral nutrition continued, as verified on day 246 by enteroclysis. The paper draws attention to the importance of conservative metabolic care in the therapy of dishiscences of intestinal anastomoses not treated by acute surgery in time. A favourable additive effect of enteral nutrition on the persisting cholestasis during parenteral nutrition is discussed.