The role of endocrine mechanisms in ventilator-associated lung injury in critically ill patients.

The critically ill subjects are represented by a heterogeneous group of patients suffering from a life-threatening event of different origin, e.g. trauma, cardiopulmonary failure, surgery or sepsis. The majority of these patients are dependent on the artificial lung ventilation, which means a life-saving chance for them. However, the artificial lung ventilation may trigger ventilation-associated lung injury (VALI). The mechanical ventilation at higher volumes (volutrauma) and pressure (barotrauma) can cause histological changes in the lungs including impairments in the gap and adherens junctions and desmosomes. The injured lung epithelium may lead to an impairment of the surfactant production and function, and this may not only contribute to the pathophysiology of VALI but also to acute respiratory distress syndrome. Other components of VALI are atelectrauma and toxic effects of the oxygen. Collectively, all these effects may result in a lung inflammation associated with a subsequent profibrotic changes, endothelial dysfunction, and activation of the local and systemic endocrine responses such as the renin-angiotensin system (RAS). The present review is aimed to describe some of the pathophysiologic aspects of VALI providing a basis for novel therapeutic strategies in the critically ill patients.

[Continuous flow ventilatory support using a multijet insufflation catheter. Physical, mathematical and clinical prerequisites and principles]. / Ventilacná podpora kontinuálnym prietokom viacdýzovým insuflacným katétrom. Fyzikálne, matematické a klinické predpoklady a princípy.

The authors present theoretical principles of a new ventilatory support continuous flow ventilatory support (CFVS) with multijet insufflation catheter (MIC). Theoretical part of the presented work reasons the need of this type of ventilatory support and explains basic mathematical and physiologic principles of described mechanical ventilation method and reveals the advantages of continuous flow ventilatory support with multijet insufflation catheter in comparison with terminal eye catheter. Physical and mathematical analysis on a model of lungs in static and dynamic conditions revealed that the difference in the value of maximal inspiratory pressure is significantly higher in the system with terminal eye catheter and confirmed that the CFVS application with multijet insufflation catheter is connected with minimal risk of barotrauma by gas flow up to 20-26 l/min. The paper concludes that continuous flow ventilatory support with multijet insufflation catheter is more efficient with the possibility of significantly higher gas flow application than with terminal eye catheter and without the risk of pressure rise in the airways and without rise of breathing work. (Fig. 10, Ref. 11.)

[Continuous flow ventilatory support with multijet insufflation catheter. Initial clinical experience]. / Ventilacná podpora kontinuálnym prietokom "viacdýzovým insuflacným katétrom". Prvé klinické skúsenosti.

BACKGROUND: Clinical application of continuous flow ventilatory support with multijet insufflation catheter is not mentioned in the literature until now. Despite the use of various forms of ventilatory support, in 10-30% of patients disweaning from mechanical ventilation is unsuccessful even if they fulfil clinical and biochemical criteria. AIM: To evaluate the efficiency of a new ventilatory support continuous flow ventilatory support with multijet insufflation catheter--in clinical conditions. METHODS: Continuous flow ventilatory support with original, patented multijet insufflation catheter with nasal installation into the trachea was used in a group of 14 patients. In a subgroup of 8 patients with chronic obstructive lung disease (COLD) was this method used for development of global respiratory insufficiency due to infectious complications and in a subgroup of 6 patients it was successfully used as a ventilatory model for weaning of patients from longterm mechanical ventilation in whom other ventilatory modes for weaning were unsuccessful. RESULTS: No patient with COLD had to be intubated and 30 minutes after the start of ventilatory support with multijet insufflation catheter mean respiratory frequency decreased from 33 +/- 2.8 to 27 +/- 2.5 d/min, paCO2 from 11.9 +/- 1.7 to 10.8 +/- 1.6 kPa and paO2 increased from 5.7 to 6.8 +/- 1.3 kPa by FiO2 of 0.3. Up to 24 h after the start of ventilatory support blood gases were improved to values characteristic for partial respiratory insufficiency. Frequency of spontaneous ventilation decreased to 20 +/- 2.2, paCO2 decreased to 6.4 +/- 1.2 kPa and paO2 continually increased reaching the value of 8.9 +/- 1.4 (FiO2 = 0.3) in the 24th hour of ventilatory support. Ventilatory support lasted in average 5 days, than it could be removed. In the second group of patients continuous flow ventilatory support was used because of unsuccessful weaning following longterm mechanical ventilation. After extubation and 30 minutes after continuous flow ventilatory support start the breathing frequency decreased to 27 +/- 2.5 d/min, paCO2 showed further fall to the value of 3.9 +/- 0.9 due to hyperventilation caused evidently by continuing paO2 decrease to the value of 8.8 +/- 1.4 kPa. Only after 60 minutes following the start of ventilatory support, by equal breathing frequency, the values of blood gases increased (paO2 to 9.9 +/- 1.5 kPa, paCO2 to 5.2 +/- 1.1 kPa) and also Vt increased (0.38 +/- 0.3) which allowed to carry on with continuous flow ventilatory support, it could be interrupted after 48 hours. CONCLUSION: On the basis of the obtained results it can be stated that continuous flow ventilatory support represents an efficient ventilatory mode in patients with chronic obstructive lung disease with global respiratory insufficiency and enables to bridge the period of management e.g. of infectious complications without intubation and mechanical ventilation. As a noninvasive ventilatory regime it can be also used of patients from longterm mechanical ventilation. Application in acute respiratory for weaning (ARF, ARDS) requires further prospective studies. (Tab. 5, Fig. 4, Ref. 28.)

[Problems posed by asymptomatic pheochromocytoma and malignant tumors of the adrenal medulla]. / Problèmes posés par les phéochromocytomes asymptomatiques et les formes malignes de tumeurs de la médullo-surrénale.

The authors analyse a group of 38 patients with a diagnosis of pheochromocytoma, in particular the topics of atypical symptomatology and malignancy. Three patients did not suffer from any subjective symptoms or other signs of pheochromocytoma ("incidentalomas"). Another three patients, although having giant tumours, only complained of atypical symptoms. Signs suspicious of malignancy were detected in 6 out of 38 patients. The authors recommend a practical approach to modern diagnostic and imaging tools for early primary diagnosis and for the early diagnosis of local recurrence and distant metastases.

Pre-operative management for surgery of pheochromocytoma.

The authors analyze 15 patients who underwent pre-operative management prior to the pheochromocytoma removal. The purpose of this analysis is to evaluate the relation between clinical and haemodynamic criteria evaluating the level of alpha-adrenergic blockade. The authors believe that pre-operative management based on clinical criteria does not necessarily ensure adequate alpha-adrenergic blockade. Invasive monitoring of haemodynamic variables is considered an important strategy for the quantification of actual haemodynamics status of patients with pheochromocytoma.

Diagnosis and treatment of cortical tumours of the suprarenal gland.

The authors report on their own groups of benign (20 patients) and malignant (14 patients) cortical tumours of the suprarenal gland. In both kinds of tumour the occurrence is higher in females. Adenoma occurred more often in the left adrenal gland and cancer in the right one. Some tumours manifested themselves by an increased production of suprarenal hormones, others were hormonally inactive and did not become manifest until the later stage of development. In the therapy of adenomas the classical lumbar approach through the 11th intercostal space is adequate, in the case of cancer and extended lumbotomy laparotomy or thoracotomy is necessary. The need of participation of other specialists in the treatment (endocrinologist, radiologist, oncologist, anaesthesiologist) is emphasized.

Germ cell testicular tumours with lung metastases: chemotherapy and surgical treatment.

Eighty patients with stage IV testicular germ cell tumours with lung metastases were treated with PVB chemotherapy and subsequent surgery in cases of residual disease. Out of 80 patients 28 (35%) achieved complete response following chemotherapy alone. Thirty-six patients (45%) with partial response underwent surgery: 17 had lymphadenectomy because of residual mass in the retroperitoneum, 15 had pulmonary surgery alone and 4 had both operations. Of these 36 patients 27 achieved complete response following cytostatic and surgical treatment. Sixteen patients died following PVB chemotherapy, 10 of them due to progression of disease, and there were six (7.5%) drug-related deaths. The authors refer to the importance of surgical treatment of residual metastatic mass in the lungs following PVB chemotherapy. Germ cell tumours of the testis are the most curable solid neoplasms treated by the oncologist. Advances in their management are due to the introduction of cisplatin-based combination chemotherapy and surgical removal of the residual mass [8]. Progress in chemotherapy of testicular tumours has changed the attitude towards thoracotomy and surgical removal of lung metastases. The aim of this study is to evaluate combined cytostatic and surgical treatment of disseminated testicular tumours with emphasis on surgical removal of residual lung metastases following chemotherapy.

[Long-term pain therapy in malignancies using epidural administration of opiates]. / Dlhodobá liecba bolesti pri malígnych ochoreniach epidurálnym podávaním opiátov.

The authors explain basic anatomical and pharmacological principles of epidural opiate analgesia. As to clinical aspects, the authors mention briefly the technique of epidural analgesia. They summarize, based on their own experience and data in the literature, the period of insertion of an epidural catheter, opiate dosage in morphine equivalents, the need of adjuvant treatment and complications. They mention briefly various techniques which can be used in epidural opiate analgesia with an outline on perspectives of this method.

Venepuncture, catheterization and failure to position correctly during central venous cannulation.

The authors analyse the incidence of puncture, catheterization and failures of positioning in a series of 420 central venous catheterizations performed in 388 patients, using six transcutaneous approaches: supraclavicular and infraclavicular subclavian, external and internal transjugular, antecubital and brachiocephalic. Puncture failures were recorded at 7.9% per 36 failures from 456 attempts, catheterization failures at 5.8% per 26 failures from 446 attempts, and misplacements at a rate of 5.7% per 23 misplacements during 420 catheterizations. The results show that, in respect of puncture, catheterization and success of positioning, the supraclavicular subclavian approach may be recommended preferentially. The internal jugular, brachiocephalic and infraclavicular subclavian approaches are also advantageous. A high rate of failures and misplacements was recorded in the antecubital and external jugular groups. The antecubital veins, however, should be reserved for orthopnoeic sitting patients, the success rate being significantly increased if the patients are sitting.

Surgical, infectious and thromboembolic complications of central venous catheterization.

The authors have analysed the incidence of specific complications in a series of 420 intracaval catheters placed in 388 patients, using six transcutaneous puncture techniques: supraclavicular and infraclavicular subclavian, external and internal jugular, antecubital and brachiocephalic approaches. Strict and moderate criteria were used to evaluate the frequency of complications. Using strict criteria, the lowest rate of surgical complications (5%) was found with the antecubital and external jugular approach, followed by infraclavicular (6.7%) and supraclavicular (9.3%) subclavian techniques; the highest rate was seen with internal jugular (10%) and brachiocephalic (15%) routes. As to inflammatory and infectious complications, the sequence was as follows: brachiocephalic (2.5%), infraclavicular (4.4%) and supraclavicular (5.3%) subclavian, and internal jugular (7%) veins; a 10% incidence was associated with external jugular and antecubital techniques. Manifest thromboembolic complications were observed only in the brachiocephalic and antecubital groups (2.5% and 10%, respectively), the overall incidence of pulmonary embolism being 0.2%. None of the approaches used can be recommended as an exclusive method of choice. The risks of central venous catheterization should be minimalized by adherence to strict principles of placing as well as care of the indwelling intravenous catheters.

Inadvertent thoracic duct catheterization during transjugular central venous cannulation. A case report.

An aberrant placement of a central venous catheter into the upper part of the thoracic duct with loop formation in the left innominate vein was observed on catheterizing via the left internal jugular vein. The misplacement, which did not have any deleterious effects, was caused by the atypical insertion site of the thoracic duct at the dorsocaudal wall of the left innominate vein and, possibly, by its incompetent closing valve. The stiffness of the nylon catheter used may also have been a contributory factor. The possible causes of this complication of central venous catheterization are discussed. The preferential use of the right internal jugular vein is stressed.

Misplacement and loop formation of central venous catheters.

Exact placement is an essential prerequisite for long-term use of a central venous catheter. Reported data show an extremely wide range of catheteral misplacements: from less than 1% to more than 60%. Some approaches appear to be less advantageous than others, but the highest rates of misplacement occur in the cubital, external jugular and saphenous veins. A series is presented of 378 radiographically controlled central venous catheters analysed for aberrant placement and loop formation. The total occurrence of faulty positioning and coiling reached 5.3%, while the respective incidences were 30% for the external jugular vein, 5.7% for the internal jugular vein, 5.5% for the infraclavicular technique of subclavian venepuncture, 5.3% for the innominate vein and 1.4% for the supraclavicular approach of subclavian venepuncture. The total frequency for pure loop formation was 2.9%. The authors discuss numerous reported data on catheter malpositioning, according to the specific techniques used, and compare them with thier own results. The relatively low incidence in the present series is possibly due to the high proportion of cases where the supraclavicular subclavian approach was used, the omission of the sphrenous/femoral and cubital techniques, and to pre-determining the length of the inserted catheteral segments.