Intraabdominalinė hipertenzija ir pilvo suspaudimo sindromas: diagnostika, įtaka organų veiklai ir gydymas

Dauginis organų nepakankamumo sindromas yra viena iš pagrindinių reanimacijos ir intensyviosios terapijos skyrių ligonių mirties priežasčių. Didėjant pažeistų organų sistemų skaičiui didėja ir mirštamumas. Nors pasiekta didelė pažanga gydant dauginį organų nepakankamumo sindromą (šiuolaikiniai dirbtinės plaučių ventiliacijos režimai, inkstų, kepenų pakaitinės terapijos metodai, ekstrakorporinė membraninė oksigenacija ir kiti gydymo būdai), tačiau ligonių, turinčių daugiau nei keturių organų nepakankamumą, mirštamumas viršija 70 % Todėl tikslinga daugiau dėmesio skirti organų nepakankamumo prevencijai ir ankstyvam kritinės būklės atpažinimui. Žalingas padidėjusio intraabdominalinio spaudimo poveikis visoms organų sistemoms yra įrodytas tiek eksperimentiniais tyrimais su gyvūnais, tiek klinikiniais tyrimais. Intraabdominalinė hipertenzija atlieka svarbų vaidmenį dauginio organų disfunkcijos sindromo patogenezėje, todėl intaabdominalinio spaudimo matavimas tapo rutininiu sunkios būklės ligonių stebėsenos rodikliu. Šioje apžvalgoje, remiantis naujausios literatūros duomenimis, apibendrinami intraabdominalinės hipertenzijos ir pilvo suspaudimo sindromo apibrėžimai, etiologija ir rizikos veiksniai, taip pat įvairūs intraabdominalinio spaudimo matavimo metodai, aptariamas intraabdominalinės hipertenzijos poveikis organų funkcijoms ir šiuolaikinės jos gydymo tendencijos.Reikšminiai žodžiai: intraabdominalinė hipertenzija, intraabdominalinis spaudimas, pilvo suspaudimo sindromas, dauginis organų disfunkcijos sindromas, dekompresinė laparotomija.Intra-abdominal hypertension and the abdominal compartment syndrome: diagnostics, effects on organ function and management The multiple organ dysfunction syndrome is one of the main causes of death in intensive care units. The more organ systems are injured the higher are mortality rates. Although there has been a significant progress in treating the multiple organ dysfunction syndrome (modern modes of mechanical lung ventilation, kidney, liver replacement therapy, extracorporeal membrane oxygenation and other techniques), the mortality rate in patients with more than four organ failures exceeds 70%. Therefore, it is reasonable to pay more attention to the prevention and early recognition of a critical illness. When the measurement of intra-abdominal pressure gradually became available in day-to-day practice, an increasing number of experimental animal testing and clinical trials have proved detrimental effects of the elevated intra-abdominal pressure on all organ systems and its role in the pathogenesis of the multiple organ dysfunction syndrome. In this review, we summarize the current literature data concerning the definitions, etiology and risk factors of intra-abdominal hypertension and the abdominal compartment syndrome as well as different techniques to measure the intra-abdominal pressure. We also discuss the pathophysiological implications of intra-abdominal hypertension on organ function and current treatment trends.Key words: intra-abdominal hypertension, intra-abdominal pressure, abdominal compartment syndrome, multiple organ dysfunction syndrome, decompressive laparotom

Impact of malnutrition on postoperative delirium development after on pump coronary artery bypass grafting

Background & aims: Even though malnutrition is frequently observed in cardiac population outcome data after cardiac surgery in malnourished patients is very rare. No thorough research was done concerning the impact of malnutrition on neuropsychological outcomes after cardiac surgery. The aim of our study was to analyze the incidence of postoperative delirium development in malnourished patients undergoing on pump bypass grafting. Methods: We performed a cohort study of adults admitted to Vilnius University Hospital Santariskiu Clinics for elective coronary artery bypass grafting. The nutritional status of the patients was assessed by Nutritional Risk Screening 2002 (NRS-2002) questionnaire the day before surgery. Patients were considered as having no risk of malnutrition when NRS-2002 score was less than 3 and at risk of malnutrition when NRS-2002 score was ≥3. During ICU stay patients were screened for postoperative delirium development using the CAM-ICU method. and divided into two groups: delirium and non delirium. The statistical analysis was preformed to evaluate the differences between the two independent groups. The logistic regression model was used to evaluate the potential preoperative and intraoperative risk factors of postoperative delirium. Results: Ninety-nine patients were enrolled in the study. Preoperative risk of malnutrition was detected in 24 % (n = 24) of the patients. The incidence of early postoperative delirium in overall study population was 8.0 % (n = 8). The incidence of the patients at risk of malnutrition was significantly higher in the delirium group (5 (62.5 %) vs 19 (20.9 %), p <0.0191). In multivariate logistic regression analysis risk of malnutrition defined by NRS 2002 was an independent preoperative and intraoperative risk factor of postoperative delirium after coronary artery bypass grafting (OR: 6.316, 95 % CI: 1.384-28.819 p = 0.0173). Conclusions: Preoperative malnutrition is common in patients undergoing elective coronary artery bypass grafting. Nutrition deprivation is associated with early postoperative delirium after on pump coronary artery bypass grafting

Vaikų ir suaugusiųjų stuburo deformacijų chirurgijos ir anestezijos protokolas: priešoperacinio ir perioperacinio ištyrimo bei gydymo algoritmas, rekomenduojamas stuburo deformacijų chirurgijoje

Spinal deformity surgery is one of the most challenging surgeries that is only performed by highly professional multidisciplinary team in dedicated spinal centres. In the paper, the authors share and present the algorithm for safe and successful management of complex spinal disorders in Vilnius University Hospital Santaros Clinics.Stuburo deformacijų chirurgija – viena iš sudėtingiausių chirurgijos sričių. Operacijas gali atlikti tik profesionalios daugiaprofilinės specialistų komandos specializuotuose stuburo chirurgijos centruose.Straipsnyje pristatomas algoritmas, taikomas Vilnius universiteto ligoninės Santaros klinikų pacientams, kuriems diagnozuojama sudėtinga stuburo patologija, kai reikia stuburo rekonstrukcinės operacijos

Jutimų suvokimas sergant juosmens ir kryžmens radikulopatija su šakneliniu skausmu: multimodalinio somatosensorinio ištyrimo prie ligonio lovos tinkamumo tyrimas

 Background. Somatosensory testing could be useful in stratifying pain patients and improving pain treatment guidelines. Bedside-suitable techniques are searched for application in daily clinical practice. This study aimed to characterize chronic unilateral lumbosacral radiculopathy (LSR) patients with radicular pain using multimodal bedside-suitable somatosensory testing. Materials and methods. We evaluated 50 chronic unilateral LSR patients with radicular pain (LSR group) and 24 controls (Control group). Sensory testing was performed using a battery of bedside sensory tests (10g monofilament, 200–400 mN brush, Lindblom rollers with controlled 25°C and 40°C temperature, and 40g neurological pin and investigator’s finger pressure). Participants had to rate their sensory perceptions on both legs at multiple test points within L3 to S2 dermatomes. Characteristics of the testing process and sensory disturbances were analyzed. Results. LSR group showed sensory disturbances in 82% of patients. The Control group showed no sensory disturbances. Sensory testing took longer (p < 0.001) in the LSR group (29.3 ± 6.5 minutes per patient) than in the Control group (20.5 ± 5.2). Nine sensory phenotypes were detected in the LSR group according to individual sensory disturbances within 5 superficial tests. Conclusions. The applied multimodal bedside-suitable somatosensory testing battery is suitable for sensory evaluation and characterization of LSR patients. Grouping of allied sensory phenotypes revealed some tendencies in pain intensity characteristics

Neinvazinė smegenų oksimetrija miego arterijos endarterektomijos metu: pritaikymas ir rezultatai

Background. Cerebral monitoring during carotid endarterectomy allows to detect brain hypoperfusion following carotid clamping and hyperperfusion after restoring the blood flow. Immediate corrections of these changes have the potential in reducing adverse neurologic outcomes. In this study we share our experience using cerebral oximetry in carotid endarterectomy surgery, as well as finding a connection between comorbidities and baseline cerebral oxygenation values. Materials and methods. A non-randomised perspective study was performed at Vilnius University Hospital Santariškių Clinics. During 2012–2013 all consecutive elective patients undergoing carotid surgery were enrolled in the study. Results. No difference was found in the baseline values on the operative and control sides (71.15% vs 76.76%, p = 0.15). After carotid clamping regional brain saturation decreased by 4.34% of the baseline on the operative side. During the clamping cerebral oxygenation was lower on the operative side (68.06% vs 77.32%, p = 0.03). Following carotid declamping the difference between operative and control side oxygenation diminished (73.57% vs 79.30%, p = 0.16). Neither diabetes nor peripheral atherosclerosis had influence on baseline cerebral oxygen saturation values. There was a tendency towards the lower cerebral oxygenation baseline for smokers (70.12% vs 76.54%, p = 0.103). Conclusions. Cerebral oximetry is a valuable method of cerebral monitoring reflecting changes in brain perfusion during carotid endarterectomy. Certain comorbidities might have a role in affecting baseline oximetry values

Assessment of risk factors for abdominal surgery patients admitted to the intensive care unit.

Saulius Vosylius, Jūratė Šipylaitė, Juozas IvaškevičiusVilniaus universiteto Anesteziologijos ir reanimatologijos klinika,Vilniaus greitosios pagalbos universitetinė ligoninė,Šiltnamių g. 29, LT-04130 VilniusEl paštas: [email protected] Įvadas / tikslas Chirurginiams sunkios būklės ligoniams po pilvo organų operacijų reikalinga ilgiau trunkanti intensyvioji terapija. Darbo tikslas – įvertinti prognostinius veiksnius, susijusius su užsitęsusiu gydymu Reanimacijos ir intensyviosios terapijos skyriuje (RITS), ir atlikti su mirštamumu susijusių veiksnių analizę. Ligoniai ir metodai Prospektyviam tyrimui atrinkti 644 chirurginiai ligoniai, po pilvo organų operacijų gydyti Vilniaus greitosios pagalbos universitetinės ligoninės RITS. Būklės sunkumas įvertintas pagal SAPS II, o organų funkcijų sutrikimo laipsnis – pagal SOFA sistemas. Pagal gydymo RITS trukmę ligoniai suskirstyti į dvi grupes: gydytų iki 2 parų ir ilgiau nei 2 paros; pagal hospitalizacijos baigtį – į pasveikusiųjų ir mirusiųjų. Rezultatai Iki RITS įgyta infekcija nustatyta 290 ligonių, daugumai jų (89%) buvo intraabdomininė infekcija. Vienos ir daugiau organų sistemų disfunkcija pirmąją parą RITS buvo 61% ligonių. Gydymo RITS trukmės vidurkis – 3 paros, ligoninėje – 17 parų. Kuo ilgiau užtruko gydymas RITS, tuo didesnei daliai ligonių pasireiškė infekcinių komplikacijų. RITS įgyta infekcija patvirtinta 59 ligoniams, dažniausiai pneumonija ir intraabdomininė infekcija. Dauginės tiesinės regresijos metodika nustatyti su ilgesne gydymo RITS trukme susiję prognostiniai veiksniai: RITS įgyta infekcija, sutrikusios funkcijos organų sistemų skaičius ir sunkios eigos sepsis. Hospitalinis mirštamumas – 18%. Jis laipsniškai didėjo daugėjant sutrikusios funkcijos organų sistemų. Dauginės loginės regresijos metodika nustatyti nepriklausomi mirštamumo ligoninėje prognostiniai veiksniai: sunkios eigos sepsis, RITS įgytos infekcijos, sutrikusios funkcijos organų sistemų skaičius, būklės sunkumas ir vyresnis amžius. Išvados RITS įgytos infekcijos, sunkios eigos sepsis ir organų sistemų funkcijų sutrikimai yra svarbiausi ilgesnę intensyviosios terapijos trukmę ir didesnį mirštamumą lemiantys prognostiniai veiksniai ligoniams po pilvo organų operacijų. Prasminiai žodžiai: chirurgija, intensyvioji terapija, infekcija, sepsis, organo disfunkcija Assessment of risk factors for abdominal surgery patients admitted to the intensive care unit Saulius Vosylius, Jūratė šipylaitė, Jjuozas Ivaškevičius Background Prolonged intensive care is often required for severely ill patients after abdominal surgery. The goal of the study was to assess the risk factors associated with prolonged stay in the intensive care unit (ICU) and the hospital mortality. Patients and methods 644 patients after abdominal surgery, admitted to the ICU, were included into a prospective study. The SAPS II system was used for the assessment of the severity of illness and the SOFA system for organ dysfunction assessment. The patients were divided into groups according to length of stay in the ICU and survival status at the hospital discharge. Results Infection acquired before ICU admission was present in 290 patients, most commonly (89%) in intra-abdominal site. 61% of patients had at least organ dysfunction on the first day. The mean length of stay in the ICU was 3 days and in the hospital 17 days. As the length of stay in the ICU increased, more patients had infection complications of diseases. An ICU-acquired infection was diagnosed in 59 patients (most commonly pneumonia and intra-abdominal infection). Multiple linear regression analysis was applied to find the variables related to prolonged stay in the ICU: severe sepsis, ICU-acquired infection and organ dysfunction score. Multiple logistic regression analysis revealed that severe sepsis, ICU-acquired infection, organ dysfunction score, severity of illness, and age were independently associated with hospital mortality. Conclusions ICU-acquired infection, severe sepsis and organ dysfunction are independent risk factors in a prolonged length stay in the ICU and in hospital mortality for patients after abdominal surgery. Keywords: surgery, intensive care, infection, sepsis, organ dysfunctio

Incidence and Risk Factors of Early Delirium after Cardiac Surgery

Introduction. The aim of our study was to identify the incidence and risk factors of delirium after cardiac surgery implementing Intensive Care Delirium Screening Checklist (ICDSC). Material and Methods. 87 patients, undergoing cardiac surgery at Vilnius University hospital, were prospectively monitored for postoperative delirium development, during intensive care unit stay. Results. The incidence of postoperative delirium was 13.30%. No statistically relevant preoperative predictors of delirium were found. The duration of surgery was significantly longer in delirium group ( versus hours, ). Patients in delirium group more often had blood product transfusions (1.50 (± 1.57) versus 0.49 (± 0.91) ) and had a higher incidence of low cardiac output syndrome (33.30% versus 3.00%, ); they were significantly longer mechanically ventilated ( versus 8.78 ± 4.77 ()) hours (OR = 1.15 ()) and had twice longer ICU stay ( versus 2.60 ± 1.10 ()) days (OR = 1.91 ()). Conclusions. The incidence of delirium after cardiac surgery was 13.3%. Independent predictors of delirium were duration of postoperative mechanical ventilation and intensive care unit stay

Epidural anesthesia in obstetrics: feelings of pregnant women, information sources and willingness to change pain relief method during next childbirth

Objective. The goal of the trial is to evaluate the influence of epidural analgesia on women’s general condition during labour; to determine if women’s level of fear and the amount of information about the pain control are important in choosing the method; to find out women’s opinion about the hospital. Methods. 100 women, who gave birth in the VULSK Obstetrics and Gynecology Centre during Dec. 2013 and Mar. 2014, were asked to fill out an antenatal satisfaction questionnaire. 41 of 100 were given epidural analgesia (1st group) and 59 received intravenous analgesia with fentanyl (2nd group). The following data were collected: women’s age, place of residence, number of births, pain relief method, strength of fear before labour, strength of pain during labour, general condition after giving birth, adverse effects, information sources of pain relief, women’s wishes to change analgesia during next labour..

Safety and effectiveness of opiate antagonist detoxification under general anesthesia

Objective. To evaluate safety and effectiveness of opiate antagonist detoxification under general anesthesia according to available prospective and retrospective data. Methods. We analyzed all detoxification cases that were performed in Vilnius University Emergency Hospital in the period of 2002–2005. Data of 65 patients from prospective, randomized, double-blind, placebo-controlled study and 21 retrospective cases were included in the study. Results. Full opiate receptor blockade was achieved in 85 cases (98.84%). No complications related to detoxification procedure or general anesthesia were recorded. Differences in procedure protocols and possible implications for clinical practice are discussed. Conclusions. The protocol of the prospective study may be recommended as a safe and effective detoxification method

Outcomes and Risk Factors of Critically Ill Patients with Hematological Malignancy. Prospective Single-Centre Observational Study

Background and Objectives: Oncohematological patients have a high risk of mortality when they need treatment in an intensive care unit (ICU). The aim of our study is to analyze the outcomes of oncohemathological patients admitted to the ICU and their risk factors. Materials and Methods: A prospective single-center observational study was performed with 114 patients from July 2017 to December 2019. Inclusion criteria were transfer to an ICU, hematological malignancy, age &gt;18 years, a central line or arterial line inserted or planned to be inserted, and a signed informed consent form. Univariate and multivariable logistic regression models were used to evaluate the potential risk factors for ICU mortality. Results: ICU mortality was 44.74%. Invasive mechanical ventilation in ICU was used for 55.26% of the patients, and vasoactive drugs were used for 77.19% of patients. Factors independently associated with it were qSOFA score &ge;2, increase of SOFA score over the first 48 h, mechanical ventilation on the first day in ICU, need for colistin therapy, lower arterial pH on arrival to ICU. Cut-off value of the noradrenaline dose associated with ICU mortality was 0.21 &mu;g/kg/min with a ROC of 0.9686 (95% CI 0.93&ndash;1.00, p &lt; 0.0001). Conclusions: Mortality of oncohematological patients in the ICU is high and it is associated with progression of organ dysfunction over the first 48 h in ICU, invasive mechanical ventilation and need for relatively low dose of noradrenaline. Despite our findings, we do not recommend making decisions regarding treatment limitations for patients who have reached cut-off dose of noradrenaline