Przypadkowe umieszczenie elektrody stymulatora w lewej komorze serca - powikłanie rzadkie, czy rzadko rozpoznawane?

Przypadkowe umieszczenie elektrody stymulatora w lewej komorze serca jest rzadko rozpoznawanym powikłaniem elektrostymulacji. Najczęściej elektroda wewnątrzsercowa przemieszcza się przez przegrodę międzyprzedsionkową lub przetrwały otwór owalny do lewego przedsionka i przez zastawkę dwudzielną do lewej komory serca. W zapisie EKG stymulacja lewej komory prowadzi do powstania wystymulowanych zespołów QRS o kształcie całkowitego bloku prawej odnogi pęczka Hisa. Na podstawie zdjęcia RTG klatki piersiowej można podejrzewać nietypowy przebieg elektrody, ale decydujące znaczenie dla rozpoznania ma badanie echokardiograficzne, zwłaszcza przezprzełykowe. Nieprawidłowe położenie elektrody w lewej komorze serca wiąże się z dużym ryzykiem powikłań zakrzepowo-zatorowych. Leczenie polega na usunięciu nieprawidłowo położonej elektrody z lewej komory lub zastosowaniu przewlekłej terapii przeciwzakrzepowej. W pracy opisano 2 przypadki nieprawidłowego umieszczenia elektrody komorowej stymulatora w lewej komorze serca. (Folia Cardiol. 2003; 10: 231–236

Przypadkowe umieszczenie elektrody stymulatora w lewej komorze serca - powikłanie rzadkie, czy rzadko rozpoznawane?

Przypadkowe umieszczenie elektrody stymulatora w lewej komorze serca jest rzadko rozpoznawanym powikłaniem elektrostymulacji. Najczęściej elektroda wewnątrzsercowa przemieszcza się przez przegrodę międzyprzedsionkową lub przetrwały otwór owalny do lewego przedsionka i przez zastawkę dwudzielną do lewej komory serca. W zapisie EKG stymulacja lewej komory prowadzi do powstania wystymulowanych zespołów QRS o kształcie całkowitego bloku prawej odnogi pęczka Hisa. Na podstawie zdjęcia RTG klatki piersiowej można podejrzewać nietypowy przebieg elektrody, ale decydujące znaczenie dla rozpoznania ma badanie echokardiograficzne, zwłaszcza przezprzełykowe. Nieprawidłowe położenie elektrody w lewej komorze serca wiąże się z dużym ryzykiem powikłań zakrzepowo-zatorowych. Leczenie polega na usunięciu nieprawidłowo położonej elektrody z lewej komory lub zastosowaniu przewlekłej terapii przeciwzakrzepowej. W pracy opisano 2 przypadki nieprawidłowego umieszczenia elektrody komorowej stymulatora w lewej komorze serca. (Folia Cardiol. 2003; 10: 231–236

The Rationale and Current Status of Endotoxin Adsorption in the Treatment of Septic Shock

Lipopolysaccharide, the main component of the outer membrane of Gram-negative bacteria is a highly potent endotoxin responsible for organ dysfunction in sepsis. It is present in the blood stream not only in Gram-negative infections, but also in Gram-positive and fungal infections, presumably due to sepsis-related disruption of the intestinal barrier. Various pathways, both extra- and intracellular, are involved in sensing endotoxin and non-canonical activation of caspase-mediated pyroptosis is considered to have a major role in sepsis pathophysiology. Endotoxin induces specific pathological alterations in several organs, which contributes to poor outcomes. The adverse consequences of endotoxin in the circulation support the use of anti-endotoxin therapies, yet more than 30 years of experience with endotoxin adsorption therapies have not provided clear evidence in favor of this treatment modality. The results of small studies support timely endotoxin removal guided by measuring the levels of endotoxin; unfortunately, this has not been proven in large, randomized studies. The presence of endotoxemia can be demonstrated in the majority of patients with COVID-19, yet only case reports and case series describing the effects of endotoxin removal in these patients have been published to date. The place of blood purification therapies in the treatment of septic shock has not yet been determined

Advanced therapeutic methods for the treatment of meningococcal septic shock — case report

BACKGROUND: Meningitis caused by Neisseria meningitidis is primarily a disease of children and young adults. If septic shock complicates the course of meningitis, it must be treated in the intensive care unit.CASE REPORT: An 18 year-old man with symptoms of meningococcal meningitis and clinical features of septic shock was admitted to the ICU. Tachycardia (heart rate 140 min-1) required vasopressor to maintain blood pressure (noradrenalin 1 μg kg-1 min-1) on admission. Respiratory failure developed (respiratory rate of 40 min-1, SaO2 79%, PaO2/FiO2 ratio = 55) and mechanical ventilatory support was used. The presence of Neisseria meningitidis was confirmed by a rapid latex agglutination test. Cefotaxime with vancomycin was administered on day one, and vancomycin was replaced by meropenem on day two. Additionally to the standard treatment of septic shock and multiorgan failure, haemoperfusion with LPS adsorber was performed to eliminate endotoxins from the bloodstream, and drotrecogin alfa was administered. Haemoperfusion was performed twice for sessions of two hours, and blood endotoxin activity decreased from 0.75 EAU to 0.4 EAU after 48 hours. The patient was admitted with signs of acute kidney injury and required continuous renal replacement therapy (Ca-Ca CVVHD, CVVHDF).CONCLUSIONS: Rapid pathogen identification, adequate antimicrobial therapy and endotoxin elimination from the bloodstream improved the haemodynamic and respiratory parameters of the patient. The application of routine plus non-standard methods of treatment of septic shock prevented the progression of the biological cascade in sepsis, and improved the patient’s clinical condition.BACKGROUND: Meningitis caused by Neisseria meningitidis is primarily a disease of children and young adults. If septic shock complicates the course of meningitis, it must be treated in the intensive care unit.CASE REPORT: An 18 year-old man with symptoms of meningococcal meningitis and clinical features of septic shock was admitted to the ICU. Tachycardia (heart rate 140 min-1) required vasopressor to maintain blood pressure (noradrenalin 1 μg kg-1 min-1) on admission. Respiratory failure developed (respiratory rate of 40 min-1, SaO2 79%, PaO2/FiO2 ratio = 55) and mechanical ventilatory support was used. The presence of Neisseria meningitidis was confirmed by a rapid latex agglutination test. Cefotaxime with vancomycin was administered on day one, and vancomycin was replaced by meropenem on day two. Additionally to the standard treatment of septic shock and multiorgan failure, haemoperfusion with LPS adsorber was performed to eliminate endotoxins from the bloodstream, and drotrecogin alfa was administered. Haemoperfusion was performed twice for sessions of two hours, and blood endotoxin activity decreased from 0.75 EAU to 0.4 EAU after 48 hours. The patient was admitted with signs of acute kidney injury and required continuous renal replacement therapy (Ca-Ca CVVHD, CVVHDF).CONCLUSIONS: Rapid pathogen identification, adequate antimicrobial therapy and endotoxin elimination from the bloodstream improved the haemodynamic and respiratory parameters of the patient. The application of routine plus non-standard methods of treatment of septic shock prevented the progression of the biological cascade in sepsis, and improved the patient’s clinical condition

Citrulline, Intestinal Fatty Acid-Binding Protein and the Acute Gastrointestinal Injury Score as Predictors of Gastrointestinal Failure in Patients with Sepsis and Septic Shock

Gastrointestinal (GI) failure can be both a cause of sepsis and a consequence of the systemic pro-inflammatory response in sepsis. Changes in biomarkers of enterocyte damage, citrulline and I-FABP (intestinal fatty acid binding protein), may indicate altered intestinal permeability and damage. The study group consisted of patients with sepsis (N = 28) and septic shock (N = 30); the control group included patients without infection (N = 10). Blood samples were collected for citrulline and I-FABP and a 4-point AGI score (acute GI injury score) was calculated to monitor GI function on days 1, 3, 5, 7, and 10. Citrulline concentrations in the study group were lower than in the control. Lower values were also noted in septic patients with shock when compared to the non-shock group throughout the study period. I-FABP was higher in the septic shock group than in the sepsis group only on days 1 and 3. Citrulline was lower in patients with GI failure (AGI III) when compared to AGI I/II, reaching significance on days 7 (p = 0.034) and 10 (p = 0.015); moreover, a higher AGI score was associated with an increased 28 day mortality (p = 0.038). The results indicate that citrulline measurements, along with the AGI assessment, have clinical potential in monitoring GI function and integrity in sepsis

Surveillance of Antibiotic Prescribing in Intensive Care Units in Poland

Antibiotic use and microbial resistance in health care-associated infections are increasing globally and causing health care problems. Intensive Care Units (ICUs) represent the heaviest antibiotic burden within hospitals, and sepsis is the second noncardiac cause of mortality in ICUs. Optimizing appropriate antibiotic treatment in the management of the critically ill in ICUs became a major challenge for intensivists. We performed a surveillance study on the antibiotic consumption in 108 Polish ICUs. We determined which classes of antibiotics were most commonly consumed and whether they affected the length of ICU stay and the size and category of the hospital. A total of 292.389 defined daily doses (DDD) and 192.167 patient-days (pd) were identified. Antibiotic consumption ranged from 620 to 3960 DDD/1000 pd. The main antibiotic classes accounted for 59.6% of the total antibiotic consumption and included carbapenems (17.8%), quinolones (14%), cephalosporins (13.7%), penicillins (11.9%), and macrolides (2.2%), respectively, whereas the other antibiotic classes accounted for the remainder (40.4%) and included antifungals (34%), imidazoles (20%), aminoglycosides (18%), glycopeptides (15%), and polymyxins (6%). The most consumed antibiotic classes in Polish ICUs were carbapenems, quinolones, and cephalosporins, respectively. There was no correlation between antibiotic consumption in DDD/1000 patient-days, mean length of ICU stay, size of the hospital, size of the ICU, or the total amount of patient-days. It is crucial that surveillance systems are in place to guide empiric antibiotic treatment and to estimate the burden of resistance. Appropriate use of antibiotics in the ICU should be an important public health care issue