Epidemiology of nosocomial colonization/infection caused by Acinetobacter spp. in patients of six surgical clinics in war and peacetime.

BACKGROUND/AIM: Acinetobacter spp. has emerged as nosocomial pathogen during the past few decades in hospitals all over the world, but it has increasingly been implicated as a serious nosocomial pathogen in military hospitals. The aim of this study was to analyse and compare the surveillance data on Acinetobacter nosocomial colonization/infection (NCI) collected during the wartime with the data collected in peacetime. METHODS: We conducted a prospective study of incidence of Acinetobacter spp. colonization/infection. Also, the two nested case-control studies were conducted. The patients with nosocomial infection (cases) were compared with those with nosocomial colonization (controls) during the two different periods, wartime and peacetime. The patients with NCI by Acinetobacter spp. were identified by the case-based surveillance. The surveillance covered all the patients in 6 surgical clinics. RESULTS: During the study periods a total of 166 patients had cultures that grew Acinetobacter spp. and the pooled rates of Acinetobacter spp. colonization and infection were significantly higher in wartime. When patients with NCI in wartime were compared with those with NCI in peacetime significant differences were observed. In the war year, the patients were more significantly males (p < 0.000). In a period of peace, most of the colonization/infections were reported from patients with certain chronic diseases (p = 0.020) and the survival of patients was more significant (p = 0.049). During the peacetime, proportions of Acinetobacter isolates resistent to ciprofloksacin, imipenem and meropenem were significantly higher (p < 0.001). CONCLUSION: This study provides additional important information about the risk factors of nosocomial Acinetobacter spp. infections in a large cohort of surgical patients. This is also the first study that directly examines epidemiological differences between NCI caused by Acinetobacter spp. during the war and peace period.

[Mechanical ventilation in patients with most severe forms of influenza A H1N1].

BACKGROUND/AIM: Pandemic of A H1N1 influenza is noted for its rapid spreading and life-threatening consequences like acute respiratory distress syndrome (ARDS) which requires mechanical ventilation (MV) and intensive therapy (IT).The aim of the study was to determine the significance of mechanical ventilation application in the presence of comorbidities on the outcome of the disease and patients with severe forms of acute influenza caused by A H1N1 virus. METHODS: Five patients with acute respiratory failure caused by A H1N1 influenza that required MV were included in the study. Course and outcome of the treatment were monitored in relation to age and sex of the patients, concomitant diseases, time of influenza beginning, a time of admittance in an intensive care unit, a time of an endotracheal intubation and MV beginning, MV duration and occurrence of secondary infections. RESULTS: Three patients were on a very prolonged MV (39, 43 and 20 days, respectively) and they all survived. Two patients with a significantly shorter duration of MV (14 and 12 days, respectively) died because of a very severe clinical course and concomitant diseases. Unexpectedly, we found a positive correlation between duration of MV and survival although two patients, who were on MV for the longest period of time (43 and 39 days, respectively), developed, as a complication, secondary bacterial pneumonia. CONCLUSION: Intensive therapy of patients with ARDS due to A H1N1 influenza virus requires MV which should be carried out according to guidelines of international expert forums. That is in accordance with our unexpected observation on negative correlation between duration of MV and fatal outcome. Intensive treatment of these patients, specially MV, can be very prolonged and, therefore, requires specialized teams of anesthesiologists, separate, isolated intensive therapy units and high level of medical staff protection, as was the case in this study, so no member of medical staff was infected.

Polymorphisms of genes encoding tumor necrosis factor-alpha, interleukin-10, cluster of differentiation-14 and interleukin-1ra in critically ill patients.

PURPOSE: The aim of the study was to determine whether distributions of tumor necrosis factor (TNF)-α(308), interleukin (IL)-10(1082), CD14(159), and IL-1ra gene intron 2 genotypes in critically ill patients are associated with outcome, underlying cause of sepsis, and type of microorganism. MATERIALS AND METHODS: Blood samples from 106 critically ill white patients were genotyped by method based on polymerase chain reaction for TNF-α(308), IL-10(1082), CD14(159), and IL-1ra gene intron 2. RESULTS: All patients with TNF-α(308)AA genotype survived; relative risk (RR) of death in patients with AG was 3.250 and with GG, 1.923 (P < .01). In patients with Gram-positive sepsis, IL-10(1082)AA and then AG genotypes were the most frequent ones (odds ratio [OR], 18.67 and 7.20, respectively; P < .01). When comparing IL-10(1082)AA with AG, RR of pancreatitis was 1.80 and OR was 3.40. When AA and GG were compared, RR was 7.33 and OR was 20.00. In patients with GG, RR of peritonitis was 4.07 and OR was 5.88 (P < .01). In patients with Gram-positive sepsis, CD14(159)CT was the most frequent one with OR of 5.25. Distribution of 6 IL-1ra gene intron 2 genotypes showed no significant association. CONCLUSIONS: Distribution of TNF-α(308) genotypes is associated with outcome, IL-10(1082) with type of microorganism and underlying cause of sepsis, and CD14(159) with type of microorganism.

Living unrelated donor kidney transplantation--a fourteen-year experience.

BACKGROUND: In countries without a national organization for retrieval and distribution of organs of the deceased donors, problem of organ shortage is still not resolved. In order to increase the number of kidney transplantations we started with the program of living unrelated - spousal donors. The aim of this study was to compare treatment outcome and renal graft function in patients receiving the graft from spousal and those receiving ghe graft from living related donors. METHOD: We retrospectively identified 14 patients who received renal allograft from spousal donors between 1996 and 2009 (group I). The control group consisted of 14 patients who got graft from related donor retrieved from the database and matched than with respect to sex, age, kidney disease, immunological and viral pretransplant status, the initial method of the end stage renal disease treatment and ABO compatibility. In the follow-up period of 41 +/- 38 months we recorded immunosuppressive therapy, surgical complications, episodes of acute rejection, CMV infection and graft function, assessed by serum creatinine levels at the beginning and in the end of the follow-up period. All patients had pretransplant negative cross-match. In ABO incompatible patients pretransplant isoagglutinine titer was zero. RESULTS: The patients with a spousal donor had worse HLA matching. There were no significant differences between the groups in surgical, infective, immunological complications and graft function. Two patients from the group I returned to hemodialysis after 82 and 22 months due to serious comorbidities. CONCLUSION: In spite of the worse HLA matching, graft survival and function of renal grafts from spousal donors were as good as those retrieved from related donors.

Predictive value of serum bicarbonate, arterial base deficit/excess and SAPS III score in critically ill patients.

Arterial base deficit/excess (BD/E) is commonly used marker of metabolic acidosis in critically ill patients, but requires an arterial puncture and blood gas analysis. We hypothesized that serum bicarbonate (HCO3), which can be routinely obtained, strongly correlates with arterial BD/E and provides equivalent predictive information. In addition, we evaluated predictive value of simplified acute physiology score III (SAPS III). Total of 152 critically ill surgical patients were included in retrospective analysis. On admission to intensive care unit sets of simultaneously obtained paired laboratory data, including an arterial blood gas and serum chemistry panel with serum HCO3 were obtained. Very strong correlation between BD/E and simultaneously measured serum HCO3 levels was found (r = 0.857, R(2) = 0.732, p < 0.01). The serum HCO3 level reliably identified a significant metabolic acidosis (AUC = 0.761, p < 0.05). BD and SAPS III were good predictors of mortality (AUCs 0.70 and 0.74, respectively). Serum HCO3 may be used as substitute to detect severe metabolic acidosis. BD and SAPS III score were good predictors of mortality.

Relation between both oxidative and metabolic-osmotic cell damages and initial injury severity in bombing casualties.

BACKGROUND/AIM: We have recently reported the development of oxidative cell damages in bombing casualties within a very early period after the initial injury. The aim of this study, was to investigate malondialdehyde (MDA), as an indicator of lipid peroxidation, and osmolal gap (OG), as a good indicator of metabolic cell damages and to assess their relationship with the initial severity of the injury in bombing casualties. METHODS: The study included the males (n = 52), injured during the bombing with the Injury Severity Score (ISS) ranging from 3 to 66. The whole group of casualties was devided into a group of less severely (ISS < 25, n = 24) and a group of severely (ISS > or = 26, n = 28) injured males. The uninjured volunteers (n = 10) were the controls. Osmolality, MDA, sodium, glucose, urea, creatinine, total bilirubin and total protein levels were measured in the venous blood, sampled daily, within a ten-day period. RESULTS: In both groups of casualties, MDA and OG levels increased, total protein levels decreased, while other parameters were within the control limits. MDA alterations correlated with ISS (r = 0.414, p < 0.01), while a statistically significant correlation between OG and ISS was not obtained. Interestingly, in spite of some differences in MDA and OG trends, at the end of the examined period they were at the similar level in both groups. CONCLUSION: The initial oxidative damages of the cellular membrane with intracellular metabolic disorders contributed to the gradual development of metabolic-osmotic damages of cells, which, consequently caused the OG increase. In the bombing casualties, oxidative cell damages were dependent on the initial injury severity, while metabolic-osmotic cell damages were not.

Nosocomial bloodstream infections in ICU and non-ICU patients.

BACKGROUND: Nosocomial bloodstream infections (BSI) create a serious health problem in hospitals all over the world. The objectives of our study were to explore putative disease markers and potential risk factors with nosocomial BSI in patients in intensive care units (ICU) and non-ICU patients and to determine risk factors associated with increased 28-day mortality rate in patients with nosocomial BSI acquired in combined medical-surgical ICU. However, the major purposes of this report were to identify epidemiologic differences between nosocomial BSI acquired in ICU and non-ICU, as well as analyses outcomes for patients with nosocomial BSI acquired in ICU. METHODS: A 1-year prospective cohort study was performed to determine the incidence of nosocomial BSI in hospitalized patients. Patient characteristics, risk factors related to health care, and source of infection of patients with BSI acquired in non-ICU were compared with those patient with BSI acquired in ICU. Also, nested case-control study of patients to nosocomial BSI acquired in ICU was performed to evaluate outcome. Patients were identified by active surveillance and positive blood culture during the study period. RESULTS: The incidence of nosocomial BSI was 2.2 per 1000 admission in non-ICU patients and 17.4 per 1000 admission in ICU patients. The 28-day crude mortality rate was 69% in ICU patients. A multivariate model showed that nasogastric tube (RR, 25.1; 95% CI: 3.845-163.85; P=.001), mechanical ventilation (RR, 13.04; 95% CI: 1.974-96.136; P=.008), and H2 blockers (RR, 12.16; 95% CI: 1.748-84.623; P=.012) were more prevalent among patients with BSI acquired in ICU, and aggressive procedures (RR, 8.65; 95% CI: 1.70-44.00; P=.009) were more prevalent among patients with BSI acquired in non-ICU patients. Risk factors independently associated with increased 28-day mortality rate in ICU patients were mechanical ventilation (OR, 8.63; 95% CI: 1.5-49.8; P=.016) and SAPS II >40 (OR, 6.0; 95% CI: 1.0-35.7; P=.049). The most common isolated nosocomial BSI pathogens (in both groups of patients) were coagulase-negative staphylococci (21%), Staphylococcus aureus (14%), and Klebsiella species (13%). Klebsiella species was the only organism independently influencing the poor outcome of nosocomial BSI in ICU patients (OR, 4.3; 95% CI: 1.2-15.3; P=.022). CONCLUSIONS: Our results show epidemiologic differences between non-ICU and ICU BSI. Also, this study suggests that severity of underlying host conditions, mechanical ventilation, and microbial agents (Klebsiella species) affect the outcome of NBI in patients in ICU.

Very early increase in nitric oxide formation and oxidative cell damage associated with the reduction of tissue oxygenation is a trait of blast casualties.

BACKGROUND: In our previous experimental studies, we found evidence for the increase of nitric oxide (NO) formation immediately after blast injury. In the present study we investigated whether NO overproduction was a trait for the period immediately after blast injury in humans. Concomitant metabolic disturbances were also studied, and compared to the alterations in other traumatized patients. METHODS: Blast casualties (group B, n = 13), surgical patients with the hip replacement or fractures, not exposed to blast effects (group S, n = 7) and healthy volunteers as controls (group C, n = 10), were examined. Both arterial and venous blood samples were taken within 6 hours, and 24 hours after blast injuries or surgical procedures, respectively. Plasma levels of nitrite/nitrate (NOx), superoxyde anion (O2-), sulfhydrils (SH), malondialdehyde (MDA) as well as acid-base status and other biochemical parameters (glucose, urea, creatinine, total proteins, albumin) were measured. RESULTS: Significant, but transient increase in plasma NOx levels occurred only in group B. It was associated with the significant increase of hemoglobin oxygen (sO2) saturation of the venous blood and the concomitant decrease of its arterial--venous difference. In group S the venous sO2 decreased, its arterial--venous difference increased, while NOx levels were within the control limits. In both groups, other parameters of arterial acid-base status were kept within the control limits throughout the examined period. The decrease of SH levels were similar in the examined groups, while the increase of O2- was greater in group B. CONCLUSION: Early NO overproduction was a trait of blast injuries in humans, contributing to the reduction of tissue the oxygenation and intensifying the oxidative cell damage that had to be considered in the therapy of casualties with blast injuries. These alterations were different from those observed in other surgical patients without blast injuries.

[New strategies in multiple organ dysfunction syndrome therapy for sepsis].

Despite more than 20 years of extensive research, sepsis and/or trauma induced multiple organ dysfunction syndrome (MODS) remain the chief cause of death in intensive care units, with mortality rates between 30% and 80%. Early goal-directed therapy (EGDT), use of drotrecogin alfa (activated), tight control of hyperglycaemia, and adrenal replacement therapy (low doses of corticosteroids), all constitute new treatment strategies. In future, a combination of therapies should be individually adjusted for each patient.

[Pheochromocytoma as a challenge for the anesthesiologist]. / Feohromocitom kao izazov za anesteziologa.

INTRODUCTION: Pheochromocytoma is a tumour of adrenal chromaffin tissue which produces extreme amounts of catecholamines, and leads to significant haemodynamic disturbances. The anaesthesiologist has an important role in diagnostic procedures of pheochromocytoma (physical examination, biochemical analyses, pharmacological tests, tomographic, scintigraphic, and genetic examinations), and is included in the preparation of the patient for surgery, maintenance of anaesthesia during operation, and postoperative intensive care. RESULTS: We reviewed 268 patients with adrenal tumours, who were operated on in the Military Medicaf Academy in Belgrade over the period 1974-2002. In 93 (34.7%) patients pheocromocytoma was confirmed. Unilateral localization of tumours was noted in 75 patients (80.6%)), bilateral in 3 patients (3.2%), ectopic in 7 patients (7.5%), and multiple in 3 patients (3.2%). Malignancy was observed in 3 cases (3.2%), and recidivation in 2 cases (2.2%). The most frequent surgical approach was intercostal--by Turner Warvick (72.4%). During a retrospective analysis of complications in perioperative period, we found 3 cases (1.1%) of cardiac arrest, with lethal outcome in one patient (0.4%). In two patients (0.8%) we noted significant intraoperative bleeding (lesion of v.cavae and aortae). In five cases (2.0%) we recorded accidental pleural unilateral lesion, splenectomy in one patient (0.4%), and wound infection in 3 cases (1.1%). DISCUSSION: Pheochromocytoma is a rare disease but it is followed by numerous, significant, and very dangerous haemodynamic disturbances. This is the reason for necessity of a multidisciplinary approach in diagnostic procedures and treatment of the disease. Endocrinologists, anaesthesiologists, and surgeons must cooperate at the same time, and only then we can achieve a timely diagnostic, adequate preoperative preparation of the patient, surgical extirpation of tumours, and intensive postoperative care. Our retrospective study shows successful treatment of 268 patients with adrenal tumours and 93 patients with pheochromocytomas. CONCLUSION: Pheochromocytoma is a disease with high mortality rate. Surgical extirpation of tumour is the only way for a successful treatment. This tumour is a great challenge for anaesthesiologists, because of numerous disturbances of vital parameters in perioperative period. Low mortality rate in our study (0.4% in all patients, and 1.07% in patients with pheochromocytoma) is the result of an adequate perioperative treatment of our patients. Treatment of this tumour needs hospitalisation in greater clinical centres with adequate personnel and equipment.