[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.

[Evaluation of relevance in concussion and damage of health by monitoring of neuron specific enolase and S-100b protein]. / Hodnocení závaznosti otresu mozku a poruchy zdraví pomocí monitorování hladin neuron specifické enolázy a proteinu S-100b v séru.

INTRODUCTION: Proteins released to the circulation from affected glial (neuron specific enolasis, NSE) or ganglial cells (S-100b protein) during traumatic brain injury might be used in diagnosis of traumatic brain injury in cases with negative finding on computer tomography scan (concussion) or in patients where the serious clinical status does not corresponde with mild changes on CT scan (diffuse axonal injury, DAI). Classification of DAI according Gennarelli considered the concussion as lower degree of DAI. MATERIALS AND METHOD: 15 patients were divided into group I of mild conccussion (n=3) with 1-day duration of hospitalisation, group II of serious concussion (n=4) with more days duration of hospitalisation with negative findings on CT scan and group III of patients with diagnosis of DAI (n=8). Blood samples were investigated by immunoanalysis for NSE and protein S-100b (Elecsys 2010, Roche). RESULTS: Values of NSE (16.30 +/- 2.33 vs. 110.48 +/- 34.99 vs. 24.07 +/- 6.29 microg/l), and protein S-100b (0.207 +/- 0.03 vs. 0.945 +/- 0.69 vs. 0.736 +/- 0.36 microg/l) overdrow the reference value in cases of group I, II, and III. We discuss the biomechanics of trauma and the blood brain barrier damage in comparison with values of NSE and S-100b protein. CONCLUSION: [corrected] We proved the significantly higher values of the NSE in group of serious concussion compared to group of DAI. We demonstrated that concussions in some cases lead to serious damage of health.

Total spondylectomy of C2: a new surgical technique.

According to the available sources, no case of total spondylectomy of C2 with preservation of roots, preservation of vertebral arteries and a short fixation without occipitocervical fusion has been so far described in the literature. We decided to perform a radical surgery in a man, now 27 y. o., with solitary metastasis of thyroid adenocarcinoma. In the first step, we applied the posterior surgical approach. The patient was placed prone on a standard operating table with a support of head fixed by adhesive plaster, with the upper cervical spine slightly bent forward. We made a mid-line incision, extending from the external occipital protuberance to the C7 spinous process, controlled bleeding and exposed the C0-C4 section. Subsequently, the entire posterior epistropheus was resected, including most of the pedicles and the entire articular processes for C2-C3 articulation. Both the C2 roots were preserved, however, we had to control quite a profuse bleeding from the venous plexus around the left root. During dissection, the dural sac was damaged in the region of the attachment of the left root, which was treated by suture and covered with Tissucol fibrin sealant. Screws 4.0 mm thick, were inserted into the lateral masses of the atlas after Harms and 4.0mm screws into the C3 and C4 articular processes. On both sides, the screws were connected with 3.2 mm rods, and a transverse stabilizer was then applied to fix the two sides together. Cancellous bone grafts were harvested from the iliac crest and a massive posterolateral and posterior fusion of C1-C4 was performed. The second operation was performed after 21 days. Transoral transmandible approach without tongue splitting was applied. The patient was placed supine on a standard operating table with a support of neck, the head was fixed by adhesive plaster and slightly bent back, and tracheostomy was inserted. An arched incision through the middle of the red lip was made, extending 2 cm straight caudally and arching across the chin and neck, in the midline. On the caudal end we made a transverse inverted T incision. Subsequently, we exposed and osteotomised the mandible using the midline Z-type incision. In order to identify the space between the anterior arch of C1 and the C4 vertebral body, the Synframe retractor was inserted with one blade opening the mouth by pressure on the upper teeth and two blades pressing the tongue caudally. Then an inverted U incision through the mucosa of pharynx was made to identify paravertebral muscles. Caspar retractor was used to separate the muscles and expose C1-C3 laterally, including transversal processes with vertebral arteries. No pathological changes were manifested on the skeleton. First we removed the middle portion of the C2 vertebral body where we did not find any tumour, only sclerotic remodelling. Subsequently, we reamed the lower middle portion of the anterior arch of C1, extracted the dens and cut off the alar ligaments and the apical ligament of dens. The entire dens was then removed. Then we continued on the right side, in the intact part and extracted part of C2 in the region of the atlantoaxial joint, including the rest of the pedicle, and the anterior portion of the transversal process up to the vertebral artery. The posterior part of the transversal process was carefully rotated around the artery and also removed. All parts were extremely hard, sclerotic. The same procedure was followed on the left side where we found a 7 x 10 mm gelatinous greyish tumour in the lateral part of C2 below the atlantoaxial joint. Other parts were again sclerotic. Liquorrhea appeared again from dissection around the C2 root on the left side, the source of which we could not clearly identify. We filled the site of the probable hole with Tissucol fibrin sealant. Between the notch in the lower part of the anterior arch of C1 and the upper end plate of the C3 vertebral body we seated a shaped SynMesh cage with sharp edges providing a very good fixation. No additional fixation was needed. Again we harvested cancellous bone grafts from the iliac crest and placed them on the sides of the cage and at the front between the anterior arch of the atlas and the C3 vertebral body. Subsequently, the muscles were approximated and the mucous tissue of the pharynx repaired. The mandible was fixed by two Miniplate System plates and supported by a dental plate. Total spondylectomy of C2 with preservation of vertebral arteries and roots stabilized only by a short fixation is an extreme surgical procedure suitable only for exceptional cases of young patients with a good bone quality. With regard to potential complications it is of vital importance to consider carefully such operation and consult the proposed therapy with the patient.

Antibody formation against beta-tubulin class III in response to brain trauma.

Brain trauma typically leads to neuronal damage and loss. Assuming a transient autoimmune response to debris of the damaged neurones, we have monitored serum titres of IgG and IgM antibodies to beta-tubulin class III (betaTcIII), which is almost exclusively found in neuronal cytoskeletons. In 15 out of 18 patients, the peak of the IgG or IgM antibody titre appeared in the serum within 3 weeks of a brain trauma.

[Intensive care for patients with severe acute pancreatitis with a significant multiorgan dysfunction]. / Intenzivní péce o nemocné s tezkou akutní pankreatitidou a významnou multiorgánovou dysfunkcí.

The aim of this retrospective study was to determine characteristic features of the onset and the course of the most severe forms of a severe acute pancreatitis with a concomittent multiorgan dysfunction syndrome. The study included patients transferred to the Intensive Care with a severe acute pancreatitis diagnosis and with a respiratory, circulatory and renal insufficiency or coagulopathy, or with the combination of the above. During the period from VII/1997 to XII/2002, 23 patients were treated. The mortality rate reached 78%. The average APACHE II score on admission was 23 in survivors, and 27 in no-survivors. Continuously high SOFA score (p < 0.05), more significant circulatory instability during the first days of the treatment, expressed by a higher need for the adrenaline use, and continuously increased CRP values during the follow-up treatment (day 7-14, p < 0.05), all of it signalized unfavourable results. In 50% of the fatal cases, renal insuficiency, requiring the use of the extracorporeal elimination method was reported while, on the other hand, none of the survivors suffered from renal insufficiency. The unfavourable course of the condition was also characterized by a need for more intensive therapies: those, who exited, had been cathetrized more often and they had required more surgical interventions. A favourable turn in the course of the disease was signalized by a drop in the serum CRP and by a decreasing need for vasopressors medication.

[Fecothorax, gangrene and the diaphragm loss--a case review]. / Fekalotorax, gangréna a ztráta bránice. Kazuistika.

Both stercoral peritonitis and pyothorax are rare but until nowadays threatening conditions. The presence of stool in the pleural cavity represents a curiosity, the gangrene and loss of the diaphragma is eminently rare. All above mentioned conditions occurred at the same time in the patient operated on for diffuse peritonitis after diverticular perforation of sigmoid. Surgery rescued peritoneal and pleural cavity. The absent diaphragma was replaced by mesh prosthesis, due to late intraabdominal complications the mesh was explantated. The patient survived and healed after repeated surgeries and long-lasting highly intensive therapy. Thanks to dislocation of viscera and adhaesive obliteration of the site of missing diaphragma left lung remained inflated and functional. The complication after 1 year--gastrobronchial fistula--was healed by left-sided pneumonectomy and suturing of the stomach.

[Nitric oxide in the treatment of acute respiratory distress syndrome]. / Uzití oxidu dusnatého ke zvládání syndromu akutní dechové tísne.

BACKGROUND: Nitric oxide (NO) is a selective pulmonary vasodilator effective in the treatment of pulmonary hypertension and hypoxemic respiratory failure. Reports in the Czech literature on the results of its therapeutic use are still scarce. METHODS AND RESULTS: Effects of inhaled NO on the changes of PaO2/FiO2 were assessed in the retrospective study. Records of artificially ventilated patients suffering from acute respiratory distress syndrome (ARDS) were reviewed. Daily highest NO dose, the highest PaO2/FiO2 ratio, duration of NO administration and death or survival of the patient was noted. Survivors and nonsurvivors, as well as responders (rise of PaO2/FiO2 by at least 20%) and non-responders were compared using Mann-Whitney and ANOVA test, alpha = 0.05. 16 patients were entered into the study, 13 (81%) responded positively to NO administration, the mortality was 56%. Comparing the age, NO dose, duration of its administration and APACHE II score in survivors and non-survivors, in respondents and non-respondents no differences were found. After NO administration the PaO2/FiO2 rose both in survivors and non-survivors (p < 0.0005). In survivors the response of oxygenation was more pronounced, although the difference did not reach the statistical significance (p = 0.07). On the days 1-3 the PaO2/FiO2 ratio was higher in survivors (p < 0.05). CONCLUSIONS: Despite the transient increase in oxygenation after NO administration, mortality of patients with ARDS remained high. NO administration could not be considered the standard method of treatment of patients with ARDS in intensive care.