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

The influence of fluid balance on intra-abdominal pressure after major abdominal surgery

Objective. The objectives of this study were to determine the incidence of intraabdominal hypertension in patients after major abdominal surgery and to evaluate the correlation of intra-abdominal pressure with fluid balance and systemic inflammatory response syndrome. Material and methods. This is a prospective observational study. Patients, admitted to intensive care unit after major abdominal surgery, were included into the study. Intra-abdominal pressure was measured via a urinary bladder catheter twice daily. Twenty-four-hour fluid balance and systemic inflammatory response syndrome criteria met by the patients were collected daily. Results. Seventy-seven patients were included into the study. Intra-abdominal hypertension was diagnosed in about 40% of the patients in the early postoperative period. The study showed a significant positive correlation between 24-hour fluid balance and daily changes in intraabdominal pressure. A significant association was also seen between the number of positive systemic inflammatory response syndrome criteria and intra-abdominal pressure, and intraabdominal pressure was significantly higher in patients with systemic inflammatory response syndrome. Besides, patients with intra-abdominal hypertension on the first postoperative day had longer length of stay in the intensive care unit. Conclusions. Intra-abdominal hypertension occurs commonly in patients after major abdominal surgery, and patients with positive 24-hour fluid balance and/or systemic inflammatory response syndrome are at risk of having higher intra-abdominal hypertensi

Intra-abdominal hypertension and multiple organ dysfunction syndrome

In clinical practice, intra-abdominal pressure is usually measured indirectly via the urinary bladder using Foley catheter. This technique is minimally invasive, safe, simple and accurate. Intra-abdominal hypertension is defined as an intra-abdominal pressure above 12 mmHg. Rapid progression of intra-abdominal hypertension will lead to abdominal compartment syndrome, which is defined as an intra-abdominal pressure greater than 20 mmHg with at least one organ failure. The incidence of intra-abdominal hypertension is variable and depends on the values used to define it and on the study population. However, the mortality rate of intra-abdominal hypertension and abdominal compartment syndrome is high. Increase in intra-abdominal pressure causes significant impairment of almost all organ systems. Even slight increase in intra-abdominal pressure has negative influence on the respiratory, cardiovascular, cerebral, gastrointestinal, hepatic, and renal functions. Intra-abdominal hypertension causes visceral organ hypoperfusion, intestinal ischemia and may also lead to bacterial translocation, release of cytokines and production of free oxygen radicals. All these factors may contribute to the development of multiple organ failure in the critically ill patients. Intravascular fluid replacement and abdominal decompression are the standards of treatment for abdominal compartment syndrome

Risk factors distribution in patients with symptomic vitamin K antagonist overdose

Aim of the study. To determine risk factors for bleeding, major bleeding and death in patients with overdose of vitamin K antagonists. Methods. The retrospective study examined patients, who have overdosed vitamin K antagonists and were admitted to Vilnius university Santariškės hospital between 2010-01-01and 2016- 10-31. Age, sex and bleeding risk factors were compared between groups with bleeding events and without bleeding events. Results. Total of 518 patients’ data were analysed, 253 (48,8%) were men, 265 (51,2%) women, average age was 73,2±11,2 years old. 298 (57,5%) had bleeding event, 149 (50%) were women, average age was 72,3±11,7 years old. Group with bleeding event were more likely to have gastrointestinal bleeding history:16 (5,4%) vs. 3 (1,4%) (p=0,017. 162 patients had major bleeding, average age was 72,8±11,8 years old, 88 (54,3%) were women. Major bleeding group also had more common gastrointestinal bleeding history - 10 (6,2%) vs. 9 (2,5%) (p=0,04). 56 (10,8% ) patients died, average age was 74,8±11,2 years old, 27 (48,2%) were women . Patients with lethal outcomes had kidney disease history more often (creatinine was over 200mmol/l) -17 (30,4%) vs. 64 (13,9%) (p=0,001). Conclusions. Patients who had symptomic warfarin overdose with bleeding or major bleeding were more likely to have gastrointestinal bleeding history. 9,4% of all bleeding event were lethal. Patients who died during hospitalization and had warfarin overdose were more likely to have kidney diseases and creatinine value over 200 mmol/l. These risk factors might be prognostic to predict if warfarin overdose will be symptomic, but futher investigation is required

Hospitalization and treatment analysis after vitamin K antagonists overdose

Aim of the study – to find risk factors for longer hospitalization and additional treatment for patients with vitamin K antagonist overdose and to describe how hospitalization length and treatment quantities change after bleeding occurs. Methods. Following information about patients with vitamin K antagonists (warfarin) overdose was analysed: bleeding risk factors, overdose outcomes, hospitalization length, bleeding treatment. Results. 116 (77,3%) patients with bleeding and 48 (43,5%) without bleeding needed additional treatment for bleeding and/or following complications. (p<0,001). Patients with bleeding event needed more red blood cell units (p<0,001), fresh frozen plasma units (p<0,001), vitamin K (p=0,03). These differences are even bigger in group with major bleeding event (p<0,001). Previously diagnosed anaemia is a risk factor for additional treatment need during hospitalization (p<0,001). Average hospitalization length was longer for patients with anaemia (p=0,05), thrombocytopenia (p=0,05) or liver disease history (p=0,04), hospitalization length was significantly longer for patients with bleeding event (p=0,003), 11,8±8,7 days and 9,1±4,6 days respectively. The average hospitalization length for patients with haemorrhagic stroke was 23,3±18,2 days. Conclusions. Vitamin K antagonists overdose requires additional treatment and longer hospitalization: average hospitalization length is 3 days longer after bleeding occurs, and red blood cell units consumption has grown 10 times over five year

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

Ar Trendelenburgo padėtis yra vienintelis būdas pagerinti vidinių jungo venų vizualizaciją?

Background. A larger cross-sectional area (CSA) of the internal jugular vein (IJV) makes catheterization easier and the Trendelenburg position is used to achieve this. Unfortunately, it is not comfortable for conscious patients. The aim was to evaluate the impact of alternative manoeuvres on the enlargement of the CSA of the IJV and to compare these manoeuvres with the Trendelenburg position. Materials and methods. A prospective study of 63 healthy volunteers was conducted. Two-dimensional ultrasound images of right IJV (RIJV) and left IJV (LIJV) were recorded at the level of the cricoid cartilage in the supine position with and without head rotation by 30 degrees during various manoeuvres. Results. The CSA of the RIJV and the LIJV significantly increased using hold of deep breath (mean size (cm2) RIJV 1.59 ± 0.82, LIJV 1.07 ± 0.64; both p < 0.001) and the Trendelenburg position (mean size (cm2) RIJV 1.5 ± 0.68, LIJV 0.99 ± 0.54; both p < 0.001). The 45-degree passive leg raise increased the CSA of only the RIJV (mean size (cm2) 1.17 ± 0.61, p = 0.024). These manoeuvres were compared with the Trendelenburg position. There was no significant difference in the size of the CSA using hold of deep breath on the LIJV (p = 0.08) and the RIJV (p = 0.203). The passive leg raise had a significantly weaker impact on the size of the CSA (p < 0.001 for both sides). Conclusions. Hold of deep breath and 45-degree passive leg raise (the latter limited for the right side only) are alternative manoeuvres to improve visualization of internal jugular veins for conscious patients. Hold of deep breath was as effective as the Trendelenburg position

Ūminio inkstų funkcijos pažeidimo vertinimas širdies chirurgijoje: glomerulų filtracijos greičio ir liesosios kūno masės reikšmė

Background: eGFR (estimated glomerular filtration rate) formulas may be inaccurate in overweight cardiac surgery patients, overestimating the kidney reserve. The aim of this study was to modify the eGFR formulas and to determine whether the modified eGFR is a more accurate predictor of acute kidney injury (AKI). Materials and methods: The patients were assigned into 4 BMI groups as follows: normal weight (18.5–25 kg/m2), pre-obesity (25–30 kg/m2), class I obese (30–35 kg/m2), class II and III obese (≥35 kg/m2). Cockcroft–Gault (CG) eGFR formula was modified by using the fat-free mass (FFM) derived from bioelectrical impedance. ROC-AUC curves were analyzed to identify the accuracy of the eGFR formulas (CG, CG modified with FFM, Mayo Clinic Quadratic equation, CKD-EPI, MDRD) to predict the AKI in each group. Results: Although all of the used equations showed similar predictive power in the normal weight and overweight category, Mayo formula had the highest AUC in predicting the occurrence of AKI (ROC-AUC 0.717 and 0.624, p35 kg/m2). Conclusions: eGFR is a poor predictor of AKI, especially in the obese patients undergoing cardiac surgery. The only equation with a moderate predictive power for the class I obese patients was the CG formula modified with the fat-free mass

Role of fat-free mass index on amino acid loss during CRRT in critically Ill patients

Background and objectives: Amino acid (AA) loss is a prevalent unwanted effect of continuous renal replacement therapy (CRRT) in critical care patients, determined both by the machine set-up and individual characteristics. The aim of this study was to evaluate the bioelectrical impedance analysis-derived fat-free mass index (FFMI) effect on amino acid loss. Materials and methods: This was a prospective, observational, single sample study of critical care patients upon initiation of CRRT. AA loss during a 24 h period was estimated. Conventional determinants of AA loss (type and dose of CRRT, concentration of AA) and FFMI were entered into the multivariate regression analysis to determine the individual predictive value. Results: Fifty-two patients were included in the study. The average age was 66.06 ± 13.60 years; most patients had a high mortality risk with APAHCE II values of 22.92 ± 8.15 and SOFA values of 12.11 ± 3.60. Mean AA loss in 24 h was 14.73 ± 9.83 g. There was a significant correlation between the lost AA and FFMI (R = 0.445, B = 0.445 CI95%: 0.541–1.793 p = 0.02). Multivariate regression analysis revealed the independent predictors of lost AA to be the systemic concentration of AA (B = 6.99 95% CI:4.96–9.04 p = 0.001), dose of CRRT (B = 0.48 95% CI:0.27–0.70 p < 0.001) and FFMI (B = 0.91 95% CI:0.42–1.41 p < 0.001). The type of CRRT was eliminated in the final model due to co-linearity with the dose of CRRT. Conclusions: A substantial amount of AA is lost during CRRT. The amount lost is increased by the conventional factors as well as by higher FFMI. Insights from our study highlight the FFMI as a novel research object during CRRT, both when prescribing the dosage and evaluating the nutritional support needed

Comparison of mortality risk evaluation tools efficacy in critically ill COVID-19 patients

Background: As the COVID-19 pandemic continues, the number of patients admitted to the intensive care unit (ICU) is still increasing. The aim of our article is to estimate which of the conventional ICU mortality risk scores is the most accurate at predicting mortality in COVID-19 patients and to determine how these scores can be used in combination with the 4C Mortality Score. Methods: This was a retrospective study of critically ill COVID-19 patients treated in tertiary reference COVID-19 hospitals during the year 2020. The 4C Mortality Score was calculated upon admission to the hospital. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores were calculated upon admission to the ICU. Patients were divided into two groups: ICU survivors and ICU non-survivors. Results: A total of 249 patients were included in the study, of which 63.1% were male. The average age of all patients was 61.32 ± 13.3 years. The all-cause ICU mortality ratio was 41.4% (n = 103). To determine the accuracy of the ICU mortality risk scores a ROC-AUC analysis was performed. The most accurate scale was the APACHE II, with an AUC value of 0.772 (95% CI 0.714–0.830; p < 0.001). All of the ICU risk scores and 4C Mortality Score were significant mortality predictors in the univariate regression analysis. The multivariate regression analysis was completed to elucidate which of the scores can be used in combination with the independent predictive value. In the final model, the APACHE II and 4C Mortality Score prevailed. For each point increase in the APACHE II, mortality risk increased by 1.155 (OR 1.155, 95% CI 1.085–1.229; p < 0.001), and for each point increase in the 4C Mortality Score, mortality risk increased by 1.191 (OR 1.191, 95% CI 1.086–1.306; p < 0.001), demonstrating the best overall calibration of the model. Conclusions: The study demonstrated that the APACHE II had the best discrimination of mortality in ICU patients. Both the APACHE II and 4C Mortality Score independently predict mortality risk and can be used concomitantly