Role of heart-rate variability in preoperative assessment of physiological reserves in patients undergoing major abdominal surgery.

BACKGROUND: Major abdominal surgery (MAS) is associated with increased morbidity and mortality. The main objective of our study was to evaluate the predictive value of heart-rate variability (HRV) concerning development of postoperative complications in patients undergoing MAS. The secondary objectives were to identify the relationship of HRV and use of vasoactive drugs during anesthesia, intensive care unit length of stay (ICU-LOS), and hospital length of stay (H-LOS). PATIENTS AND METHODS: Sixty-five patients scheduled for elective MAS were enrolled in a prospective, single-center, observational study. HRV was measured by spectral analysis (SA) preoperatively during orthostatic load. Patients were divided according to cardiac autonomic reactivity (CAR; n=23) and non-cardiac autonomic reactivity (NCAR; n=30). RESULTS: The final analysis included 53 patients. No significant difference was observed between the two groups regarding type of surgery, use of minimally invasive techniques or epidural catheter, duration of surgery and anesthesia, or the amount of fluid administered intraoperatively. The NCAR group had significantly greater intraoperative blood loss than the CAR group (541.7±541.9 mL vs 269.6±174.3 mL, p<0.05). In the NCAR group, vasoactive drugs were used during anesthesia more frequently (n=21 vs n=4; p<0.001), and more patients had at least one postoperative complication compared to the CAR group (n=19 vs n=4; p<0.01). Furthermore, the NCAR group had more serious complications (Clavien-Dindo ≥ Grade III n=6 vs n=0; p<0.05) and a greater number of complications than the CAR group (n=57 vs n=5; p<0.001). Significant differences were found for two specific subgroups of complications: hypotension requiring vasoactive drugs (NCAR: n=10 vs CAR: n=0; p<0.01) and ileus (NCAR: n=11 vs CAR: n=2; p<0.05). Moreover, significant differences were found in the ICU-LOS (NCAR: 5.7±3.5 days vs CAR: 2.6±0.7 days; p<0.0001) and H-LOS (NCAR: 12.2±5.6 days vs CAR: 7.2±1.7 days; p<0.0001). CONCLUSION: Preoperative HRV assessment during orthostatic load is objective and useful for identifying patients with low autonomic physiological reserves and high risk of poor post-operative course.

[Antibiotic therapy of hospital-acquired pneumonia and its pharmacoeconomics].

BACKGROUND: Important hospital-acquired infections include pneumonia, mainly because of the increasing resistance of bacterial pathogens to antimicrobials and the associated potential failure of antibiotic therapy. The present study aimed at determining the most frequent etiological agents of hospital-acquired pneumonia (HAP) and assessing the relationship between 30-day mortality and adequacy of antibiotic therapy. Based on the obtained information, optimal patterns of antibiotic therapy were to be defined, including a pharmacoeconomic perspective. METHODS: In patients with clinically confirmed HAP, bacterial etiological agents were identified, their susceptibility to antimicrobials was determined and statistical methods were used to assess the relationship between adequacy of antibiotic therapy and 30-day mortality. RESULTS: The study comprised 68 patients with clinically confirmed HAP. The most common etiological agents were strains of Pseudomonas aeruginosa (30.8 %), Klebsiella pneumoniae (23.1 %) and Burkholderia cepacia complex (15.4 %). Gram-negative bacteria accounted for 86.5 % of all bacterial pathogens. The overall mortality reached 42.5 %. In the subgroup of patients with inadequate antibiotic therapy, 30-day mortality was significantly higher (83.3 %) than in the subgroup with adequate therapy (30.0 %; p = 0.002). The risk for 30-day mortality was 2.78 times higher in case of inadequate antibiotic therapy (95%CI: 1.52-5.07). The proportion of Pseudomonas aeruginosa strains was significantly higher in the subgroup of patients with inadequate antibiotic therapy than in those with adequate therapy (67 % vs. 27 %; p = 0.032). CONCLUSION: Results of the present study suggest a significant relationship between mortality of patients with HAP and ineffective antibiotic therapy due to resistance of the bacterial pathogen. Thus, it is clear that initial antibiotic therapy must be based on qualified assumption of sufficient activity against the most common bacterial pathogens and results of surveillance of bacterial resistance in the relevant epidemiological unit. At the same time, however, it must be stressed that it is impossible to cover all potential variants of the etiological agents and their resistance phenotypes.

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

BACKGROUND: Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. METHODS: We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. RESULTS: We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). CONCLUSIONS: We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Epidemiology of hospital-acquired pneumonia: Results of a Central European multicenter, prospective, observational study compared with data from the European region.

BACKGROUND: Hospital-acquired pneumonia (HAP) is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of HAP. This project was aimed at collecting multicenter epidemiological data on patients with HAP in the Czech Republic and comparing them with supraregional data. METHODS: This prospective, multicenter, observational study processed data from a database supported by a Czech Ministry of Health grant project. Included were all consecutive patients aged 18 and over who were admitted to participating intensive care units (ICUs) between 1 May 2013 and 31 December 2014 and met the inclusion criterion of having HAP. The primary endpoint was to analyze the relationships between 30-day mortality (during the stay in or after discharge from ICUs) and the microbiological etiological agent and adequacy of initial empirical antibiotic therapy in HAP patients. RESULTS: The group dataset contained data on 330 enrolled patients. The final validated dataset involved 214 patients, 168 males (78.5%) and 46 females (21.5%), from whom 278 valid lower airway samples were obtained. The mean patient age was 59.9 years. The mean APACHE II score at admission was 21. Community-acquired pneumonia was identified in 13 patients and HAP in 201 patients, of whom 26 (12.1%) had early-onset and 175 (81.8%) had late-onset HAP. Twenty-two bacterial species were identified as etiologic agents but only six of them exceeded a frequency of detection of 5% (Klebsiella pneumoniae 20.4%, Pseudomonas aeruginosa 20.0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6.2% and Burkholderia cepacia complex 5.8%). Patients infected with Staphylococcus aureus had significantly higher rates of early-onset HAP than those with other etiologic agents. The overall 30-day mortality rate for HAP was 29.9%, with 19.2% mortality for early-onset HAP and 31.4% mortality for late-onset HAP. Patients with late-onset HAP receiving adequate initial empirical antibiotic therapy had statistically significantly lower 30-day mortality than those receiving inadequate initial antibiotic therapy (23.8% vs 42.9%). Patients with ventilator-associated pneumonia (VAP) had significantly higher mortality than those who developed HAP with no association with mechanical ventilation (34.6% vs 12.7%). Patients having VAP treated with adequate initial antibiotic therapy had lower 30-day mortality than those receiving inadequate therapy (27.2% vs 44.8%). CONCLUSIONS: The present study was the first to collect multicenter data on the epidemiology of HAP in the Central European Region, with respect to the incidence of etiologic agents causing HAP. It was concerned with relationships between 30-day patient mortality and the type of HAP, etiologic agent and adequacy of initial empirical antibiotic therapy.

Patient survival, predictive factors and disease course of severe sepsis in Czech intensive care units: A multicentre, retrospective, observational study.

BACKGROUND: Severe sepsis/septic shock is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of severe sepsis. The EPOSS (Data-based Evaluation and Prediction of Outcome in Severe Sepsis) project launched in 2011 was aimed at collecting data on patients with severe sepsis/septic shock. METHODS: The EPOSS study processes data from the EPOSS project database, and is a retrospective, multicentre, observational study. This included all consecutive patients aged 18 and over who were admitted to participating ICUs from 1 January 2011 to 5 November 2013 and met the inclusion criteria of severe sepsis/septic shock. The primary endpoint was to analyse the relationship between in-hospital mortality (either in ICU or after discharge from ICU) and the type and number of fulfilled diagnostic and treatment interventions during the first 6 h after the diagnosis of severe sepsis/septic shock. RESULTS: The collected dataset involved 1082 patients meeting the criteria of severe sepsis/septic shock. Following data validation, a final dataset of 897 patients was obtained. The average age of the patient group was 64.7 years; mortality at discharge from EPOSS ICUs was 35.5% and from hospital 40.7%. Of the 10 evaluated diagnostic and treatment interventions within the initial 6 hours of identifying severe sepsis/septic shock (i.e. fulfilment of SSC bundles), four or five diagnostic and treatment interventions were administered to 58.4% patients. Combined diagnostic and treatment interventions associated with the lowest in-hospital mortality were: CVP of ≥8-12 mm Hg & MAP of ≥65 mm Hg & Urine output at ≥0.5 mL/kg/h & Lactate of ≤4.0 mmol/L & Initial lactate measured & Antibiotics in the first hour. Lactate at <4 mmol/L and MAP of ≥65 mm Hg remained statistically significant even after adjustment for patient age and APACHE II score. Statistically significantly increased in-hospital mortality was found in patients admitted from general departments (45.7%) or from other ICUs (41.6%), compared to a lower in-hospital mortality of patients transferred from outpatient clinics (26.5%) or Emergency (38.0%). Severe sepsis/septic shock patients transferred from the department of internal medicine were associated with a higher in-hospital mortality (45.1%) than surgical patients (35.5%). CONCLUSIONS: The most effective measures associated with the lowest in-hospital mortality in septic shock patients were CVP of ≥8-12 mm Hg, MAP of ≥65 mm Hg, urine output at ≥0.5 mL/kg/h, initial lactate level of ≤4.0 mmol/L and administration of antibiotics within the first hour.

[Gastric lavage after peroral intoxication--controversial views]. / Výplach zaludku pri perorální intoxikaci--sporné pohledy na problematiku.

Gastric lavage after ingestion of excessive amounts of a drug/poison--yes or no? If yes, at what time intervals from ingestion? On one side stand some authors who emphasize the complications, contraindications, and low yield of this procedure. These authors recommended that gastric lavage should be performed only within 30-60 minutes after ingestion of toxic doses of a drug/poison. Later lavage usually has no clinical benefit. On the other side stand some other authors who recommend gastric lavage in patients as late as 6 hours after intoxication. In some cases, when the ingested substance slows gastric emptying, they even recommend lavage until 24 hours after intoxication. Based on our experience, it is necessary to support strongly the second group of the authors and recommend the extension of the time interval when to perform gastric lavage in intoxication.

[Validity comparison of various biological samples from lower airway and their contribution for the detection of nosocomial pneumonia etiological agents]. / Porovnání validity ruzných vzorku biologického material z dýchacích cest a jejich prínosu v detekci puvodcu nozokomiální pneumonie.

BACKGROUND: The aim of the study was to compare the validity of bronchial secretion sampling and bronchoscopy-assisted protected specimen brushing (PSB) in patients with hospital-acquired pneumonia (HAP). MATERIALS AND METHODS: In patients with HAP, bronchial secretion samples (aspiration of lower airway secretions from an orotracheal tube with a suctioning catheter) and PSB (bronchoscopy-assisted sampling from the most affected area of the lung, verified by CT scan) were taken at the same time. Both samples were processed by semiquantitative routine microbiological techniques. Identification of microorganisms was performed by standard microbiological techniques using the MALDI-TOF automated system. For similarity or identity determination of bacterial isolates from bronchial secretion sampling and PSB, pulsed-field gel electrophoresis was used. RESULTS: Thirty patients were enrolled into the study. Thirty pairs of bronchial secretion samples and PSB samples were obtained and processed. The samples were positive in 23 patients (77 %) and 15 patients (50 %), respectively. In 15 cases, the same pathogen was determined in both samples, and in all those cases, the isolates were genetically identical. CONCLUSION: The results of the study show that bronchial secretion samples analysis enabled identification of all pathogens that were identified by PSB. Given the high sensitivity of the bronchial secretion aspiration technique and genetic identity of isolates in both samples, bronchial secretion sampling may be recommended for determining HAP etiological agents as the samples are much easier to obtain from patients.

Interaction of rocuronium with human liver cytochromes P450.

Rocuronium is a neuromuscular blocking agent acting as a competitive antagonist of acetylcholine. Results of an inhibition of eight individual liver microsomal cytochromes P450 (CYP) are presented. As the patients are routinely premedicated with diazepam, possible interaction of diazepam with rocuronium has been also studied. Results indicated that rocuronium interacts with human liver microsomal CYPs by binding to the substrate site. Next, concentration dependent inhibition of liver microsomal CYP3A4 down to 42% (at rocuronium concentration 189 µM) was found. This effect has been confirmed with two CYP3A4 substrates, testosterone (formation of 6ß-hydroxytestosterone) and diazepam (temazepam formation). CYP2C9 and CYP2C19 activities were inhibited down to 75-80% (at the same rocuronium concentration). Activities of other microsomal CYPs have not been inhibited by rocuronium. To prove the possibility of rocuronium interaction with other drugs (diazepam), the effect of rocuronium on formation of main diazepam metabolites, temazepam (by CYP3A4) and desmethyldiazepam, (also known as nordiazepam; formed by CYP2C19) in primary culture of human hepatocytes has been examined. Rocuronium has caused inhibition of both reactions by 20 and 15%, respectively. The results open a possibility that interactions of rocuronium with drugs metabolized by CYP3A4 (and possibly also CYP2C19) may be observed.

Resection versus biopsy of glioblastomas in eloquent brain areas.

AIM: The aim of this study was to compare resection and biopsy of glioblastoma (GBM) in eloquent brain areas (EBA). METHODS: This was a prospective evaluation of 38 patients with GBM in EBA. 22 were treated by surgical resection and 16 by biopsy. Preoperative KPS, neurological status and size of lesion on MRI were assessed. One week and three months postoperatively KPS, neurological status and Performance Status (PS) WHO were evaluated. Extent of resection (EOR) and overall survival (OS) were described. Overall mean age of the patients was 64.3 years, the mean lesion size in the resection group was 47.7 mm and in the biopsy group 51.0 mm. RESULTS: Worsening or development of permanent neurological deficits 3 months after surgery were significantly lower in the resection group (23%), than the biopsy group (94%). In the resection group the median pre and postoperative KPS three months after surgery was 80.0. In the biopsy group the median pre and postoperative KPS was 68.1 one week after the procedure. In the resection group, 3 months after surgery, the median PS was 1, in the biopsy group one week after surgery the median PS was 2. The difference was statistically insignificant. The mean OS after resection was 12.2 months, and after biopsy 3.5 months. The difference was highly statistically significant. The mean EOR was 90%. CONCLUSION: This is the first prospective study, to our knowledge, that compares the results of resection and biopsy of primary GBM in EBA. For patients in good clinical condition with tumors in or near EBA, recommended is as radical resection of GBM as possible.

Risk of sympathectomy after anterior and lateral lumbar interbody fusion procedures.

AIM: The aim of this study was to identify retrospectively, lumbar sympathectomy (SE) using thermography (TG) and to evaluate clinically, the severity of post-sympathectomy (post-SE) dysfunction after anterior and lateral lumbar interbody fusion procedures (ALIF, XLIF). METHODS: Twenty eight patients with suspected SE were referred for TG to both legs. They completed our questionnaire on severity of difficulties after SE. We evaluated the ability of physical examinations to reveal the SE in contrast to TG and compared the symptoms (warmer leg and inhibited leg sweating) of SE with questionnaire responses as subjective measure and TG as objective measure. RESULTS: SE was diagnosed in 0.5% after ALIF at L5/S1, in 15% after ALIF at Th12-L5 and in 4% after XLIF at T12-L5. SE severely reduced the quality of life in two cases. The ability to distinguish differences in leg temperature by palpation after SE was found in 32%. All physical examinations together were insufficient for reliably disclosing SE. Subjective symptoms of SE were often false positive and proven SE by TG was often a clinically false negative. CONCLUSION: This is the first study to examine post-SE dysfunction objectivelya using TG after ALIF and XLIF, and the first to evaluate clinically, the severity of the post-SE syndrome. Before surgery we cannot foresee potentially poor SE results. For this reason, injury to the sympathetic chain during surgery must be avoided. The advantage of TG for identifying SE is its non-invasiveness and reliability.

A comparison of complication rate between anterior and lateral approaches to the lumbar spine.

AIM: The aim of this study was to compare the complication rate of traditional minimally invasive anterior with the new minimally invasive lateral trans-psoatic retroperitoneal approaches to the intervertebral discs at levels T12-L5. METHODS: A review of all cases of minimally invasive anterior (ALIF) and lateral (XLIF) intervertebral disc surgery at levels T12-L5, treated at the Department of Neurosurgery from January 1996 to September 2011. The ALIF group consisted of 120 and the XLIF group consisted of 88 patients. Preoperative diagnoses were: degenerative disc disease, failed back surgery syndrome, spondylolisthesis, retrolisthesis and posttraumatic disc injury. The surgical steps are described. All surgical intraoperative and postoperative complications directly related to the spinal surgery were prospectively documented. The outcome measure was rate of complications. RESULTS: In the ALIF group there were no major complications, only 35 minor intra- and postoperative complications in 32 patients (26.6%). The main complication was lumbar post-sympathectomy syndrome in 19 patients (15.8%). In the XLIF group there were 26 complications in 22 patients (25%). One major intraoperative complication was partial and transient injury to the L5 nerve root (1.1%). There were 25 minor postoperative complications in the XLIF group in 21 patients (23.9%), mainly transient pain of the left groin or anterior thigh in 11 patients (12.5%) or numbness in the same dermatomas in 9 patients (10.2%). Statistically there was no difference between the ALIF and XLIF groups in complication rate. CONCLUSION: Anterolateral and lateral retroperitoneal minimally invasive approaches to levels T12-L5 disc spaces are safe procedures with only minor complications and one exception. The rate of complications was similar in both groups. In the case of ALIF, the particular complication was post-sympathectomy syndrome. The main complication of XLIF was transient nerve root injury in one patient due to underestimation of the procedure in the outset. Intraoperative neuromonitoring during XLIF surgery is fully recommended.

Radiofrequency upper thoracic sympathectomy in the treatment of critical upper limb ischemia--a case series.

BACKGROUND: Patients with significant medical and social problems resulting from impaired perfusion of the upper limbs caused by micro- or macro-angiopathy are now frequent in clinical practice. Vasospastic disease of the upper limbs of combined origin is a difficult condition to treat by conservative methods and therapeutic strategies are usually multidisciplinary. In addition to standard pharmacotherapy, treatment may involve regional anaesthesia, thoracoscopic or radiofrequency sympathectomy and surgical treatment of defects, including plastic surgery. METHODS: This paper describes our successful work in the treatment of upper limb critical ischemia using radiofrequency upper thoracic sympathectomy. RESULTS: In three case reports we present the results of radiofrequency thermolysis applied to treat patients with chronic defects of the hand and fingers. These patients were diagnosed with upper limb critical ischemia of combined origin, standard conservative treatment methods failed and surgical intervention was originally not indicated, however, radiofrequency thermolysis proved to be beneficial. CONCLUSIONS: Radiofrequency thoracic sympathectomy could improve peripheral perfusion of the upper limbs and thereby contribute to healing of chronic defects, reduction of pain and improvement in the quality of life of the patients.

Surgical complications of the anterior approach to the L5/S1 intervertebral disc.

AIM: The aims of this study were to describe the incidence and type of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at the level of the L5/S1 intervertebral disc. METHODS: A retrospective review of 175 patients: 103 women and 72 men, average age 45, who had undergone anterior spinal surgery at level L5/S1 from January 2001 to February 2011. The preoperative diagnoses were: degenerative disc disease in 87 (50%), failed back surgery syndrome in 53 (30%) and spondylolisthesis in 35 patients (20%). The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disc L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented. RESULTS: Intraoperative pathological-anatomical anomalies were found in 34 patients (19%) and intra - and postoperative minor complications in 24 patients (12%) but no serious complications. The main intraoperative complication was peritoneal opening without visceral injury (5%) and the main postoperative complication was weakness of the right abdominal wall (3%). CONCLUSION: . Retroperitoneal access and surgery at level L5/S1 disc space is a safe procedure when performed by a knowledgeable and experienced spine team. During surgical planning for an anterior approach to the LS spine, the surgeon must carefully assess the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications.

Intraoperative reversal of neuromuscular block with sugammadex or neostigmine during extreme lateral interbody fusion, a novel technique for spine surgery.

PURPOSE: Extreme lateral interbody fusion (XLIF) is a method for stabilization of the lumbar spine. Intraoperatively, the surgeon identifies the lumbar nerve roots with a stimulator to prevent their injury. The objective of this study was to determine the extent to which shallow rocuronium-induced neuromuscular block must be intraoperatively reversed for reliable identification of nerve roots. METHODS: General anesthesia (midazolam-propofol-sufentanil-oxygen/air/sevoflurane-rocuronium) was administered to all patients. Train-of-four (TOF) stimulation of the ulnar nerve at 15-s intervals and electromyographic response of the adductor pollicis muscle were used. During operation, the surgeon stimulated the lumbar nerve roots (5-10 mA) to identify their course. At the appearance of two twitches to the TOF stimuli, sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg) was administered. When the response to nerve root stimulation appeared, the TOF ratio was recorded. RESULTS: When the response to nerve root stimulation with 10 mA became detectable, the median (range) TOF ratios were 0.67 (0.50-0.81) and 0.65 (0.42-0.71) after sugammadex and neostigmine, respectively. Similarly, TOF ratios at the first detectable response to stimulation with 5 mA were 0.88 (0.67-0.93) and 0.83 (0.61-0.93). After sugammadex and neostigmine, the respective intervals until TOF ratio ≥0.90 were 2.0 (0.8-3.3) and 15.9 (7.3-28.8) min. CONCLUSION: Intraoperative reversal of shallow rocuronium-induced block with either sugammadex or neostigmine is an efficient method. For reliable detection of lumbar nerve roots with a stimulating current of 10 mA, the block should be reversed to a TOF ratio of at least 0.70. For a current intensity of 5 mA, the TOF ratio should reach 0.90.

Can difficult intubation be easily and rapidly predicted?

AIM: Failed endotracheal intubation and inadequate ventilation with subsequent insufficient oxygenation can result in serious complications potentially leading to permanent health damage. Difficult intubation may occur not only in patients with apparent pathologies in the orofacial region but also, unexpectedly, in those without abnormalities. This study aimed at finding anthropometric parameters that are easy to examine and that would aid in predicting difficult intubation. METHOD: A case-control study was undertaken. Based on defined criteria, 15 parameters were examined in patients with unanticipated difficult intubation. The parameters included a previous history of difficult intubation, pathologies associated with difficult intubation, clinical symptoms of airway pathology, the Mallampati score, upper lip bite test, receding mandible, and cervical spine and temporomandibular joint movement. Thyromental, hyomental and sternomental distances and inter-incisor gap were measured. The methods were precisely defined and the measurements were carried out by a trained anesthesiologist. Statistical analysis was performed on data from 74 patients with difficult intubation and 74 control patients with easy intubation. RESULTS: Significant predictors of difficult intubation were inter-incisor gap (IIG), thyromental distance (TMD) and class 3 limited movement of the temporomandibular joint. The IIG and TMD cut-offs were set at 42 mm and 93 mm, respectively. CONCLUSION: The results will be used to confirm these predictors in an anesthesiology clinic along with the aid of the laryngoscopic findings to improve the prediction of unanticipated difficult intubation.

Influence of age and gender on the pharmacodynamic parameters of rocuronium during total intravenous anesthesia.

AIMS: To compare the pharmacodynamics of 0.6 mg kg(-1) rocuronium in young and older patients of both genders during total intravenous anesthesia. METHODS: Following local ethics committee approval and informed consent, patients scheduled for surgery under total intravenous anesthesia (propofol/sufentanil) were divided into 4 study groups: 37 males aged 20-40, 40 males aged 60-75 yrs, 43 females aged 20-40 and 38 females aged 60-75 yrs. Neuromuscular block following rocuronium (0.6 mg kg(-1)) was monitored: train-of-four [TOF] stimulation of the ulnar nerve at 15-s intervals, EMG of the adductor pollicis muscle. The onset time (from application of rocuronium to maximum depression of T(1)), clinical duration (from application to 25% recovery of T(1)), and time to full spontaneous recovery (from application to TOF-ratio ≥ 0.9) were determined for each patient. The Kruskal-Wallis test was used to compare differences between groups; P<0.05 was considered statistically significant. RESULTS: The onset time (median [interquartile range]) in the respective groups was 90 [80-110](BCD), 135 [116-165](AC), 75 [60-90](ABD), and 120 [90-146](AC) seconds. The clinical duration was 30 [25-42](BCD), 58 [53-67](AD), 50 [40-65](AD), and 85 [70-90](ABC) min. Interval to full spontaneous recovery was 59 [51-67](BCD), 102 [75-106](A), 76 [66-91](AD), and 128 [94-137](AC) min. ((A)P<0.05 vs. young males, (B)P<0.05 vs. elderly males, (C)P<0.05 vs. young females, (D)P<0.05 vs. elderly females). CONCLUSION: Females and older patients were more sensitive to rocuronium.

Hospital-acquired pneumonia in ICU patients.

BACKGROUND: This prospective study aimed at assessing the effect of initial antibiotic therapy on the mortality of patients with hospital-acquired pneumonia (HAP) by analyzing bacterial pathogens and their resistance to antimicrobial agents. METHODS: Included were patients hospitalized in the Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc in 2009 who developed HAP. Bacterial pathogens and their resistance to antibiotics were identified using standard microbiological methods. The patient's mortality with respect to their initial antibiotic therapy was statistically analyzed. RESULTS: The group comprised 51 patients with HAP. Early-onset HAP was identified in 7 (14%) patients and late-onset HAP in 44 (86%) patients. The most frequent bacterial pathogens were strains of Klebsiella pneumoniae, Pseudomonas aeruginosa, Burkholderia cepacia complex and Escherichia coli, together accounting for 72%. Eighteen patients died directly due to HAP, an overall mortality rate of 35%. If initial therapy effective against the bacterial pathogen was selected, 21 patients survived and 9 died. If the bacterial pathogens were resistant to the selected initial antibiotic therapy, 9 patients died and 12 survived. CONCLUSIONS: The mortality rates were 30% and 43% for adequate and inadequate antibiotic therapy, respectively. Given the small group of patients, the difference has low statistical significance. However, it does document the clinical impact of bacterial resistance on the survival or death of patients with HAP.

Inter-observer reproducibility of 15 tests used for predicting difficult intubation.

AIM: To determine the inter-observer reproducibility of 15 tests used for predicting difficult tracheal intubation (DI). MATERIAL AND METHODS: Following local ethics committee approval and informed consent, 101 volunteers were examined by two assessors using 15 tests for predicting DI. The two assessors who were blinded to the results of the other, examined each volunteer independently. Cohen's kappa (κ) or first-order agreement coefficient (AC1) were used to measure agreement between assessor ratings on a qualitative scale. Agreement between two quantitative outcomes was described using the intraclass correlation coefficient (ICC) and Pearson's (PCC) or Spearman's (SCC) correlation coefficients. The following interpretation of the coefficients was used: poor (< 0.20), fair (0.21-0.40), satisfactory (0.41-0.60), good (0.61-0.80), and excellent (0.81-1.00). RESULTS: Respective coefficients of inter-rater agreement and correlation coefficients were determined for the following parameters: pathologies associated with DI (κ=0.662, AC1=0.990), clinical impression (κ=-0.013, AC1=0.969), modified Mallampati test (κ=0.503, AC1=0.861), upper lip bite test (κ=0.370, AC1=0.897), temporo-mandibular joint movement (κ=0.088, AC1=0.797), max. anteroflexion of C-spine (ICC=0.136, SCC=0.391), max. retroflexion of C-spine (ICC=0.020, SCC=0.284), mandibular length (ICC=0.301, SCC=0.553), neck circumference (ICC=0.832, SCC=0.928), hyo-mental distance (ICC=0.378, SCC=0.472), thyro-mental distance (ICC=-0.002, PCC=0.265), sternomental distance (ICC=0.674, PCC=0.815), and finally, inter-incisor gap (ICC=0.695, PCC=0.785). Two tests (positive history of DI and retrogenia), were excluded from calculation because no positive cases were found. CONCLUSION: Best inter-rater agreement was found for the assessment of neck circumference while the highest discrepancies between raters were in goniometrically-measured mobility of the C-spine. Many of the pre-operative airway tests had only fair inter-observer reproducibility. This may be one reason why models for predicting difficult intubation are not universally reliable.