[Show abstract][Hide abstract] ABSTRACT: This case report presents a 49 year-old female with type 1 diabetes admitted to the intensive care unit with acute respiratory failure and severe diabetic ketoacidosis with an initial measurement of blood glucose level of 1,200 mg L⁻¹, pH 6.78, serum HCO₃ ⁻ 3.2 mmoL L⁻¹ and BE -31.2 mmoL L⁻¹. Analysis of the blood gasometric parameters with the Stewart approach and the traditional Henderson-Hasselbalch concept enabled the discovery of metabolic acidosis caused by unidentified anions (mainly ketons). A treatment protocol with intensive fluid management with 0.9% NaCl, intensive intravenous insulin therapy, and potassium supplementation was administered. Analysis of the gasometric parameters after 12 hours of treatment according to the Stewart approach compared to the Henderson-Hasselbalch concept disclosed that metabolic acidosis caused by the unidentified anions has resolved almost completely and been replaced by metabolic hyperchloremic acidosis. The hyperchloremic acidosis was caused by the intensive fluid resuscitation with 0.9% NaCl, which contains a high chloride load, exceeding the chloride levels observed in human serum. Fluid management with balanced fluids other than saline was continued, together with intravenous insulin infusion, potassium supplementation, and 5% glucose administration. Analysis of this case study revealed the advantages of the Stewart approach to acid base abnormalities compared to the traditional Henderson-Hasselbalch concept. The Stewart approach allows the diagnosis of the exact causes of severe life-threatening metabolic acidosis and the appropriate modification of the therapeutic mangement of patients with diabetic ketoacidosis.
Preview · Article · Jan 2014 · Anaesthesiology Intensive Therapy
[Show abstract][Hide abstract] ABSTRACT: Interpreting acid base disturbances according to the physicochemical Stewart approach allows the cause of such abnormalities to be discovered. This method is based on three independent variables: SID (strong ion difference), mainly sodium and chloride; weak acids concentration - Atot, mainly albumins and phosphate; and carbon dioxide tension - pCO₂. These three independent variables are responsible for the change of water dissociation and for the change in H+ concentration and, consequently, the change in serum pH value. The SID value of the fluids administered to a patient is responsible for the change of serum SID value and therefore causes a change in the patient's acid base status. During the infusion of a given fluid, the SID value of the serum becomes closer to the SID value of that fluid; on the other hand, the infusion causes a decrease in Atot concentration. In order to avoid acid base disturbances connected with fluid administration, the SID value of fluids being administered should be greater than 0 and lower then the serum SID. It has been suggested that fluids should be given of which the SID value is as close as possible to the actual serum HCO₃ concentration. Knowing the SID value of the fluid administered, and the serum HCO₃ concentration, one can expect a change of serum pH after a fluid infusion. Administering a fluid with a SID greater than the HCO₃ concentration causes a pH increase towards alkalosis. Likewise, administering a a fluid with a SID lower than the HCO₃ concentration causes a pH decrease towards acidosis. It seems that knowledge of the electrolyte concentration and the SID value of an administered fluid is an important factor regarding acid base disturbances.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
To investigate the pharmacokinetics and pharmacodynamics of ciprofloxacin in critically ill patients after the first intravenous administration of 400 mg.
Plasma concentrations were measured in 20 critically ill patients (mean [SD]; age, 55.5 [16.5] years; weight, 80.3 [16.9] kg; and creatinine clearance, 110.0 [71.5] mL/min). Four blood samples were drawn at the following time points 0, 0.5, 6 , 8 hours after infusion. Ciprofloxacin concentrations were determined by high-performance liquid chromatography.
In the cases where ciprofloxacin was applied in targeted antibiotic therapy the minimum inhibitory concentrations (MIC) were ≤0.5 mg/l. The maximum and minimum plasma concentrations of ciprofloxacin were 1.74 (0.58-7.90) and 0.45 (0.16-2.96) mg/l, respectively. The main pharmacokinetic parameters for ciprofloxacin in the analyzed patients were as follows: k(el), 0.21 h-1; t(1/2kel), 3.37 h; AUC(0-inf), 10.10 mg×h/l; AUMC(0-last), 15.36 mg×h(2)/l; MRT, 1.71 h; V(d), 214.8 l; Cl, 39.70 l/h. Considering the maximum value of MIC (0.5 mg/l) only 30% and 25% of analyzed patients had desired values of the PK/PD indexes AUIC>125 and C(max) /MIC>10, respectively.
The target plasma concentrations after the first dose of ciprofloxacin were reached only in a few critically ill patients. Considerable inter-subject variability for PK/PD parameters in ICU patients requires systematic monitoring.
No preview · Article · Sep 2012 · Advances in Medical Sciences
[Show abstract][Hide abstract] ABSTRACT: Antibiotics are the most commonly used drugs in intensive care unit patients and their supply should be based on pharmacokinetic/pharmacodynamic rules. The changes that occur in septic patients who are critically ill may be responsible for subtherapeutic antibiotic concentrations leading to poorer clinical outcomes. Evolving in time the disturbed pathophysiology in severe sepsis (high cardiac output, glomerular hyperfiltration) and therapeutic interventions (e.g. haemodynamically active drugs, mechanical ventilation, renal replacement therapy) alters antibiotic pharmacokinetics mainly through an increase in the volume of distribution and altered drug clearance. The lack of new and efficacious drugs and increased bacterial resistance are current problems of contemporary antibiotic therapy. Although intermittent administration is a standard clinical practice, alternative methods of antibiotic administration are sought, which may potentialise effects and reduce toxicity as well as contribute to inhibition of bacterial resistance. A wide range of studies prove that the application of continuous infusion of time-dependent antibiotics (beta-lactams, glycopeptides) is more rational than standard intermittent administration. However, there are also studies which do not confirm the advantage of one method over the other. In spite of controversy the continuous administration of this group antibiotics is common practice, because the results of both studies point to the higher efficacy of this method in critically ill patients. Authors reviewed the literature to determine whether any clinical benefits exist for administration of time-dependent antibiotics by continuous infusion. Definite specification of the clinical advantage of administration this way over standard dosage requires a large-scale multi-centre randomised controlled trial.
[Show abstract][Hide abstract] ABSTRACT: Splenic artery aneurysm is the most common aneurysm of visceral vessels. Their rupture usually leads to massive bleeding, being a direct life threat. Splenic artery aneurysms usually rupture into the free peritoneal cavity, and much less frequently into the lumen of the gastrointestinal tract.
We describe the case of a 38-year-old male patient, who, as a result of chronic pancreatitis, developed a false aneurysm of the splenic artery, which initially caused necrosis of the large intestine and bleeding into its lumen, and subsequently necrosis of the posterior stomach wall with the aneurysm rupture to the stomach lumen with a dramatic course.
The case described confirms that splenic artery aneurysm can be a cause of bleeding to both upper and lower parts of the gastrointestinal tract, and the aneurysm rupture is usually of a dramatic and life-threatening course.
Full-text · Article · Feb 2012 · Medical science monitor: international medical journal of experimental and clinical research
[Show abstract][Hide abstract] ABSTRACT: During the adhesive locomotion of land snails a series of short dark transverse bands, called pedal or foot waves, is visible ifa moving snail's ventral surface is observed through a sheet of glass. Moreover, the mucus secreted from the pedal glands and some pedal epithelial cells forms a thin layer which acts as a glue augmenting adherence, while also acting as a lubricant under the moving parts of the snail's foot. The relationships between velocity and the frequency of pedal waves as well as changes in the volume of small air bubbles under foot waves were analyzed by means of digital recordings made through a glass sheet on which the snails were moving. On the ventral surface of a moving snail foot, the adhering parts of the foot constituted about 80% of the total area, while several moving parts only about 20%. The single moving region of the foot (the pedal wave) amounted to about 3% of snail length. The epithelium in the region of the pedal wave was arched above the substrate and was also more wrinkled than the stationary epithelium, which enabled the forward motion of each specific point of epithelium during the passage of a pedal wave above it. The actual area of epithelium engaged by a pedal wave was at least 30% greater than the area of the epithelium as recorded through a glass sheet. In the region of the pedal wave, the tiny subepithelial muscles acting on the epithelium move it up in the front part of the wave, and then down at the end of the wave, operating vertically in relation to the substrate. In the middle part of the wave, the epithelium only moves forward. In summary, during the adhesive locomotion of snails, the horizontal movement of the ventral surface epithelium proceeds as temporally separate phases of upward, forward and downward movement.
[Show abstract][Hide abstract] ABSTRACT: The transepithelial potential difference and changes of diameter of isolated snail intestine as index of its motility were studied in immersed bath in control conditions and after gentle stimulation by 60 seconds of washing of the intestinal lumen. Immediate depolarization and 20% augmentation of the lumen were observed during the stimulation. After stimulation, additional transient depolarization of the transepithelial potential difference and gradual diminution of intestine lumen back to control values over a period of 20 minutes occurred. The immediate reaction was greatly influenced by the presence of sodium or chloride ion transport inhibitors, however, the late phase of the response was not. It is hypothesized that changes of transepithelial electrogenic ion transport and of intestinal motility during the stimulation mirror the inflow of intestinal content and after completion of stimulation may be related to its storage.
[Show abstract][Hide abstract] ABSTRACT: Dilated cardiomyopathy is characterised by significant enlargement of cardiac chambers, which can lead to functional mitral regurgitation. Surgery is a widely accepted treatment of secondary mitral regurgitation. Conventional cardiac surgery has a high procedural risk and therefore new techniques for percutaneous repair of mitral valve are being developed. The CARILLON system is one of devices that is implanted into the coronary venous system, which enables tension of the mitral ring in order to improve coaptation of the leaflets.
Echocardiographic analysis of the CARILLON system implantation efficacy evaluated directly and one month after implantation.
The study in included 9 patients, aged 58.56 +/- 6 years, with severe functional mitral regurgitation, who fulfilled the following echocardiographic criteria: large central jet ł 4 cm(2) or ł 20% of the left atrium area or wall-impinging eccentric jet reaching the pulmonary veins, vena contracta (VC) ł 0.30 cm, effective regurgitant orifice area (ERO) ł 0.2 cm(2), regurgitant volume (RV) ł 30 ml or regurgitant fraction (RF) > 30%. Exclusion criteria were: concomitant severe tricuspid valve insufficiency, significant organic mitral valve pathology, chronic atrial fibrillation, foreign body in the coronary sinus, or thrombus in the left atrial appendage. The prerequsite for implanting the device was a significant reduction in the mitral regurgitation jet observed by transesophageal echo-cadiography (TEE), seen during the procedure. After one month, a transthoracic echocardiography (TTE) was performed to evaluate mitral regurgitation by analysing the same parameters assessed before implanting CARILLON to the coronary sinus.
A significant improvement of VC after the procedure, in comparison to the value before the procedure (0.43 +/- 0.12 vs. 0.66 +/- 0.14 cm, p < 0.05), was observed. This improvement was lower one month after the implantation of the device (0.35 +/- 0.1 cm, p < 0.005). The ratio of the jet area to the left atrial area was reduced from 54.96 +/- 11.18% to 38.57 +/- 9.79% (p < 0.005) and sustained after a month at 36.33 +/- 10.15% (p < 0.005). Other echocardiographic parameters of evaluation of mitral regurgitation tended to improve, however the differences did not reach statistical significance. The ERO in subsequent studies was: 0.25 +/- 0.09 cm(2), 0.23 +/- 0.07 cm(2), and 0.24 +/- 0.07 cm(2), and RV decreased from 33.06 +/- 11.81 ml before the procedure, to 32.33 +/- 7.84 ml one month after the procedure.
The CARILLON system implantation to the coronary venous system in patients with secondary mitral regurgitation can lead to the improvement of selected echocardiographic indices of mitral regurgitation.
Full-text · Article · Jan 2010 · Kardiologia polska
[Show abstract][Hide abstract] ABSTRACT: Toxic epidermal necrolysis (TEN) is a severe, potentially fatal, predominantly drug-induced disease characterized by extensive damage of stratified squamous epithelium followed by loss of its integrity. To date over 100 medications related to TEN manifestation have been described. Methods of treatment are still a matter of great controversy due to inability to perform double-blind, placebo-controlled studies. In the paper the case of a 26-year-old man with TEN involving 100% of the body surface area, transferred to a specialist department after 7 days' duration of disease, is described. The causative factor was difficult to establish. Combined treatment with high doses of glucocorticosteroids, cyclosporin A and plasmapheresis were administered. Despite the severe state of the patient at admission, therapeutic success was achieved due to administration of combined treatment. In our opinion, crucial for therapeutic success is early administration of aggressive systemic treatment whose activity includes the greatest possible number of elements involved in the pathogenesis of this potentially lethal disease.
No preview · Article · Jan 2010 · Postepy Dermatologii I Alergologii
[Show abstract][Hide abstract] ABSTRACT: Hyperglycemia in sepsis is managed by intensive insulin therapy, which can cause hypoglycemia.
The aim of the study was to evaluate the glycemic profile as well as safety and effectiveness of a nurse-controlled insulin therapy protocol in patients with severe sepsis and septic shock.
The study included 16 septic patients who died (nonsurvivors) and 61 septic patients who survived. Glycemia was measured every 4 h, and the dose of insulin infusion was adjusted to maintain glycemia of 4.4 mmol/l to 8.3 mmol/l. We analyzed glycemia levels and daily variations, insulin dose, episodes of hypo- and hyperglycemia.
Nonsurvivors and survivors had similar mean glycemia levels (7.38 vs. 7.08 mmol/l; p = 0.20) and insulin requirements (median [Me] = 26.9 vs. 23.9 units/d; p = 0.22; Me = 1.7 vs. 1.4 units/h; p = 0.25). Daily glycemia variation (Me = 4.81 vs. 3.03 mmol/l; p <0.001), episodes of hypoglycemia (18.8% vs. 3.3%; p = 0.02), spontaneous severe hypoglycemia (12.5% vs. 0%; p = 0.006) and hyperglycemia (75.0% vs. 45.9%; p = 0.04) were higher and more frequent in nonsurvivors. Three of 5393 blood samples (0.05%) met severe insulin-induced hypoglycemia criteria, and 74.4% of samples met the recommended range of 4.4-8.3 mmol/l.
Patients who died experienced more episodes of hyperglycemia, spontaneous hypoglycemia and greater variation in the daily glycemia level. Daily glycemia variation is more reliable than a mean glycemic level in evaluating glucose homeostasis in septic patients. Few episodes of severe insulin-induced hypoglycemia occurred while using the nurse-controlled insulin therapy protocol.
No preview · Article · Oct 2009 · Polskie archiwum medycyny wewnȩtrznej
[Show abstract][Hide abstract] ABSTRACT: The guidelines for management of sepsis are constantly updated, nevertheless sepsis is still a difficult clinical problem, especially as its treatment often ends in failure. Hospitalized cancer patients diagnosed with sepsis are especially concerned, as sepsis death rate is significant in that group of patients. The aim of the study was to evaluate and compare cancer- and non-cancer patients diagnosed with sepsis.
The medical records of 56 patients diagnosed with sepsis from January 1. 2007 to August 1. 2008 were reviewed retrospectively. Patients were divided into two groups: 1 group--patients with sepsis and cancer (S+N), II group--patients with sepsis without cancer (S). The etiology of sepsis, primary infectious sources, chosen clinical and laboratory parameters and mortality were analysed.
56 patients were involved in the study. The mean age for S+N patients was higher than for group S (61.3 vs. 45.5 years; p = 0.005). The mean APACHE II score value at the day of admission for the whole population was 22.1 +/- 8.8 (8-45), for S+N group--25.3 +/- 10.3 (12-41) and for group S--21.2 +/- 8.3 (8-45) (p = 0.308). The estimated risk of hospital death was retrospectively 43.4%, 53.3% and 39.0%. Patients in group S+N required larger infusion of minimal noradrenaline doses than the other patients (p = 0.015). The mortality rate was 14.3% and was higher in group S+N than in group S (16.7 vs. 13.6%). Mortality was also significantly higher among patients with larger lactate blood concentration (death: 4.6 vs. survival: 1.9 mmol/l; p = 0.020) and greater base deficit (death: -6.79 vs. survival: -2.34 mmol/l; p = 0,0006). Patients of lower mean arterial pressure (60.8 vs. 75.9 mmHg; p = 0.007) and who required larger noradrenaline infusion (0.514 vs. 0.232 microg/kg/min; p = 0.0009) at the day of admission had a significantly higher risk of death.
The analysis did not indicate evidently higher risk of more severe sepsis's course in cancer sepsis patients. However the severity of patients' general condition estimated by the APACHE II score and the mortality in this group of patients was higher (statistically insignificant results). Patients in group S+N required larger minimal doses of noradrenaline and larger infusion of colloid at the day of admission. The mortality was determined by the haemodynamic disturbance and the severity of general condition, rather than the cancer diagnosis per se.
No preview · Article · Jul 2009 · Polski merkuriusz lekarski: organ Polskiego Towarzystwa Lekarskiego
[Show abstract][Hide abstract] ABSTRACT: Toluene diisocyanate (TDI) due to its widespread use in industry is one of the most common and well-known causes of occupational asthma and Reactive Airways Dysfunction Syndrome (RADS). In this study the impact of TDI on the electrophysiological properties of the airways wall, particularly on the mechanisms of absorption of sodium ions and chloride ions secretion was evaluated.
Isolated rabbit tracheal wall (from outbred stock animals) was mounted in an apparatus for electrophysiological experiments by means of Ussing method and was mechanically stimulated by the jet flux of specified fluid directed onto the mucosal surface of the tissue from a peristaltic pump. The measured parameters were: transepithelial potential difference under control conditions (PD, mV), after mechanical stimulation (dPD or physiological reaction of hyperpolarization, mV) and electric resistance (R, Omega cm2). When TDI (0.035 mM) was added to stimulation fluid, only the immediate reaction was identified and when it was added to incubation fluid and other experimental fluids, the late (post-incubation) reaction was determined. The experiments involving the inhibition of Na+ by amiloride and Cl- by bumetanide were also performed.
A series of functional tests for 72 pieces of tracheal wall from 36 animals were performed. It has been shown that short-term exposure to TDI significantly changed the course of reactions to mechanical stimulation. Also after incubation in the presence of TDI, the reactions to mechanical stimulation were changed in relation to control conditions.
The immediate reaction of the isolated rabbit tracheal wall after exposure to TDI depends on the duration of exposure and on the physiological condition of the tissue in respect of sodium and chloride ion transport.
No preview · Article · Feb 2009 · International Journal of Occupational Medicine and Environmental Health
[Show abstract][Hide abstract] ABSTRACT: Usefulness and economic aspects of microbiological analysis of central venous catheter (CVC) tips in diagnosis of the catheter-related bloodstream infection (CRBSI).
Retrospective study of an adult intensive care unit in a university hospital. Catheter removal was performed when the clinical state of the patient indicated that the catheter could be the source of infection or inflammation was observed at the puncture site.
We microbiologically studied 238 CVC tips according to the Maki method and 723 blood samples from 120 septic patients treated during a 21-month period (32.9% of all patients treated in this time period). In 115 cases (48.4%), the tips were positive. Bacteremia was ascertained in 181 blood samples (24.1%), and 168 samples were collected at the time of CVC removal. In blood samples taken from 20 patients (3% of total blood samples), 25 cases of the same pathogens were isolated from CVC tips. In 12 cases, pathogens found in blood and CVC tips were also cultured in other places. In 13 cases (5.5% of tips), CVCs were the source of CRBSI. Positive predictive value (PPV) and negative predictive value reached 11% and 91%, respectively. The total cost of CVC tip monitoring was about 4000 euro.
Our data support the hypothesis that colonization of CVC is rarely responsible for CRBSI. Relatively low PPV renders tips culture useless as a method of diagnosing CRBSI. Based on these results, the routine microbiological monitoring of CVC tips was discontinued to reduce the cost of treatment.
No preview · Article · Feb 2009 · Medical science monitor: international medical journal of experimental and clinical research
[Show abstract][Hide abstract] ABSTRACT: Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue bacterial infection. We present a serious case of a 43-year-old male who suffered from necrotizing fasciitis of the left leg in whom a delayed diagnosis caused multiorgan dysfunction.
Early recognition of important symptoms is essential in the management and surgical debridement of necrotizing fasciitis. Treatment should include comprehensive supportive measures (early goal-directed therapy, adequate ventilation strategy, activated protein C dosage, tight glucose control, steroids, renal replacement therapy) and early antibiotic therapy based on microbiologic monitoring. The pathophysiology and etiologic factors of necrotizing fasciitis are discussed.
[Show abstract][Hide abstract] ABSTRACT: Contemporary antimicrobial therapy should be directed by objective criteria which allow for maximal effectiveness of treatment with minimal side effects. ITU patients are at special risk because of profound changes in the organism that may after both the pharmacokinetics and the pharmacodynamics of drugs. Therapeutic concentrations are frequently not achieved, leading to multiple bacterial resistance. Typical parameters (CI, Vd, T0,5, AUC, Cmax) do not adequately describe the altered PK/PD in sepsis. Three other indicators, Cmax/MIC, AUC/MIC, and T>MIC allow for better prediction of therapeutic effects. For drugs where effectiveness is concentration dependent (eg. aminoglycosides), the Cmax/MIC indicator should be used. For the successful use of the AUC dependent drugs (fluorchinolones), the AUC/MIC indicator should used and kept above >125. The T>MIC indicator is important for betalactam antibiotics, macrolides and clindamycin. The standardization of these indicators should improve the effectiveness of antimicrobial therapy is sepsis.
[Show abstract][Hide abstract] ABSTRACT: Mitral regurgitation may result from left ventricular dilatation and cause progression of heart failure. Percutaneous techniques for mitral valve repair are under development. Techniques utilizing a trans-coronary venous approach exploit the anatomical relationship between the mitral annulus and the venous system of the heart. The coronary sinus, great cardiac vein and the origin of the anterior interventricular vein surround the posterior mitral annulus. This enables percutaneous approaches to annuloplasty for mitral regurgitation. Devices can be implanted into the coronary veins that modify the shape and size of the mitral annulus. We present a case of ischaemic mitral regurgitation successfully treated by use of a percutaneous approach, the Carillon Mitral Contour System. Significant reduction of the mitral regurgitation jet was observed. The patient was discharged 4 days after the procedure. During the follow-up visits, the patient showed an improved general condition and increased exercise capacity. Procedural steps are shown in detail and the current status of the coronary sinus based technique is discussed. Percutaneous techniques for mitral valve repair may be an attractive alternative to cardiac surgery in heart failure patients with secondary mitral regurgitation. The Carillon Mitral Contour System is under ongoing clinical evaluation in the AMADEUS trial.
Full-text · Article · Apr 2007 · Kardiologia polska