Faktori koji utiču na cenu antibiotske terapije i ishod kod kritično obolelih pacijenata - 'real-life' studija

Background/Aim. Critically ill patients are at very high risk of developing severe infections in intensive care units (ICUs). Procalcitonin (PCT) levels are eleveted in the circulation in patients with bacterial sepsis and PCT might be useful in guiding antibiotic treatment. The aim of this study was to estimate factors influencing patients survival and treatment cost in ICU with special emphasis on the impact of PCT serum levels use in guiding antimicrobial therapy. Methods. The study was conducted from August 2010 to May 2012 in the Intensive Therapy Unit, Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy (MMA), Belgrade, Serbia. All adult critically ill patients with sepsis and/or trauma admitted in the ICU were included in the study. This study included only the cost of antimicrobial therapy in the ICU and the cost for PCT analysis. We used prices valid in the MMA for the year 2012. PCT in serum was measured by homogeneous immunoassay on a Brahms Kryptor analyzer. Results. A total of 102 patients were enrolled. The mean patients age was 55 ± 19 years and 61.8% of patients were male. The mean length of stay (LOS) in the ICU was 12 ± 21 days. There was a statistically significant difference (p lt 0.001) between the sepsis and trauma group regarding outcome (higher mortality rate was in the sepsis group, particularly in the patients with peritonitis who were mostly women). The patients younger than 70 years had better chance of survival. LOS, the use of carbapenems and PCT-measurement influenced the cost of therapy in the ICU. Conclusions. The obtained results show that age, the diagnosis and gender were the main predictors of survival of critically ill patients in the ICU. The cost of ICU stay was dependent on LOS, use of carbapenems and PCT measurement although the influence of these three factors on the outcome in the patients did not reach a statistical significance.Uvod/Cilj. Kritično oboleli pacijenti imaju veliki rizik od razvoja teških infekcija u jedinicama intenzivne terapije (JIT). Nivo prokalcitonina (PCT) u cirkulaciji je povišen kod bolesnika sa bakterijskom sepsom, tako da PCT može biti koristan u praćenju antibiotske terapije. Cilj ove studije bio je da se ustanove faktori koji utiču na ishod i troškove lečenja u JIT u našoj ustanovi sa posebnim naglaskom na uticaj korišćenja serumskog nivoa PCT u vođenju antimikrobne terapije. Metode. Studija je sprovedena od avgusta 2010. godine do maja 2012. godine u Jedinici intenzivne terapije Klinike za anesteziologiju i intenzivnu terapiju Vojnomedicinske akademije (VMA) u Beogradu, Srbija. Svi kritično oboleli sa sepsom i/ili traumom koji su primljeni u JIT bili su uključeni u studiju. Studijom su obuhvaćeni samo troškovi antimikrobne terapije u JIT i troškovi PCT analize. Koristili smo cenovnik VMA za 2012. godinu. PCT u serumu je meren tehnikom homogenog imunoeseja na Brams Kriptor analizatoru. Rezultati. Studijom su bila obuhvaćena 102 bolesnika. Prosečna starost bolesnika iznosila je 55 ± 19 godina, a 61,8% bolesnika bili su muškarci. Prosečna dužina boravka u JIT (lenght of stay LOS) iznosila je 12 ± 21 dana. Postojala je statistički značajna razlika (p lt 0.001) između ishoda lečenja u grupi sa sepsom u odnosu na grupu sa traumom. Bolesnici mlađi od 70 godina imali su bolju šansu da prežive. Dužina boravka, upotreba karbapenema i merenje PCT uticali su na cenu terapije u JIT. Zaključak. Dobijeni rezultati pokazuju da su godine života, dijagnoza i pol bili glavni prediktori preživljavanja kritično obolelih u JIT. Cena terapije zavisila je od dužine boravka u JIT, upotrebe karbapenema i merenja PCT, ali uticaj ovih faktora na ishod lečenja nije dostigao statističku značajnost

Upotreba beta-laktamskih antibiotika u jedinicama intenzivne terapije - patofiziološki, farmakokinetički, farmakodinamički i farmakoekonomski pristup

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Effect of mechanical pressure-controlled ventilation in patients with disturbed respiratory function during laparoscopic cholecystectomy

Background/Aim: Laparoscopic cholecystectomy is considered to be the gold standard for laparoscopic surgical procedures. In ASA III patients with concomitant respiratory diseases, however, creation of pneumoperitoneum and the position of patients during surgery exert additional negative effect on intraoperative respiratory function, thus making a higher challenge for the anesthesiologist than for the surgeon. The aim of this study was to compare the effect of intermittent positive pressure ventilation (IPPV) and pressure controlled ventilation (PCV) during general anesthesia on respiratory function in ASA III patients submitted to laparoscopic cholecystectomy. Methods. The study included 60 patients randomized into two groups depending on the mode of ventilation: IPPV or PCV. Respiratory volume (VT), peak inspiratory pressure (PIP), compliance (C), end-tidal CO2 pressure (PETCO2), oxygen saturation (SpO2), partial pressures of O2, CO2 (PaO2 and PaCO2) and pH of arterial blood were recorded within four time intervals. Results. There were no statistically significant differences in VT, SpO2, PaO2, PaCO2 and pH values neither within nor between the two groups. In time interval t1 there were no statistically significant differences in PIP, C, PETCO2 values between the IPPV and the PCV group. But, in the next three time intervals there was a difference in PIP, C, and PETCO2 values between the two groups which ranged from statistically significant to highly significant; PIP was lower, C and PETCO2 were higher in the PCV group. Conclusion. Pressure controlled ventilation better maintains stability regarding intraoperative ventilatory parameters in ASA III patients with concomitant respiratory diseases during laparoscopic cholecystectomy

Influence of perioperative administration of amino acids on thermoregulation response in patients underwent colorectal surgical procedures

Background. Hypothermia in the surgical patients can be the consequence of long duration of surgical intervention, general anesthesia and low temperature in operating room. Postoperative hypothermia contributes to a number of postoperative complications such as arrhythmia, myocardial ischemia, hypertension, bleeding, wound infection, coagulopathy, prolonged effect of muscle relaxants. External heating procedures are used to prevent this condition, but some investigations reported that infusion of aminoacids during surgery can induce thermogenesis and prevent postoperative hypothermia. Case report. We reported two males who underwent major colorectal surgery for rectal carcinoma. One patient received Aminosol 15% solution, 125 ml/h, while the other did not. The esophageal temperatures in both cases were measured every 30 minutes during the operation and 60 minutes after in Intensive Care Unit. We were monitoring blood pressure, heart rate, ECG, and shivering. Patient who received aminoacids showed ameliorated postoperative hypothermia without hypertension, arrhythmia, or shivering, while the other showed all symptoms mentioned above. Conclusion. According to literature data, as well as our findings, we can conclude that intraoperative intravenous treatment with amino acid solution ameliorates postoperative hypothermia along with its complications.

Hemodynamic stability in total intravenous propofol anesthesia with midazolam coinduction versus general balanced anaesthesia in laparoscopic cholecystectomy

Background/Aim. Laparoscopic cholecystectomy can be a greater challenge for anesthesiologist than for surgeon if the patient is ASA III with concomitant cardiovascular diseases. The aim of our study was to compare the effect of total intravenous anesthesia (TIVA - propofol with midazolam) and general balanced anesthesia (GBA - midazolam, thiopenton, nitrous oxide and O2) on hemodynamic stability in the ASA III patients who underwent laparoscopic cholecystectomy. Methods. In our study, 60 patients were randomized into two groups depending on whether they received TIVA or GBA. Heart rate, systolic, diastolic and mean arterial pressure were monitored continuously and recorded in five time intervals. Results. Statistical analysis showed that TIVA with propofol provides better hemodynamic stability (less than 10% deviation from basal values for each measured parameter) then GBA group (p &lt; 0.01). Conclusion. Total intravenous anesthesia with propofol provides better hemodynamic stability for ASA III patients with concomitant cardiovascular diseases then GBA

Efficacy of external warming in attenuation of hypothermia in surgical patients

Background/Aim. Hypothermia in surgical patients can be the consequence of long duration of surgical intervention, general anaesthesia and low temperature in operating room. Postoperative hypothermia contributes to a number of postoperative complications such as arrhythmia, myocardial ischemia, hypertension, bleeding, wound infection, coagulopathy, and prolonged effect of muscle relaxants. External heating procedures are used to prevent this condition. The aim of this study was to evaluate the efficiency of external warming system in alleviation of cold stress and hypothermia in patients who underwent major surgical procedures. Methods. The study was conducted in the Military Medical Academy in Belgrade. A total of 30 patients of both genders underwent abdominal surgical procedures, randomly divided into two equal groups: the one was externally warmed using warm air mattress (W), while in the control group (C) surgical procedure was performed in regular conditions, without additional warming. Oesophageal temperature (Te) was used as indicator of changes in core temperature, during surgery and awakening postoperative period, and temperature of control sites on the right hand (Th) and the right foot (Tf) reflected the changes in skin temperatures during surgery. Te and skin temperatures were monitored during the intraoperative period, with continuous measurement of Te during the following 90 minutes of the postoperative period. Heart rates and blood pressures were monitored continuously during the intraoperative and awakening period. Results. In the W group, the average Te, Tf and Th did not change significantly during the intraoperative as well as the postoperative period. In the controls, the average Te significantly decreased during the intraoperative period (from 35.61 ± 0.35ºC at 0 minute to 33.86 ± 0.51ºC at 120th minute). Compared to the W group, Te in the C group was significantly lower in all the observed periods. Average values of Tf and Th significantly decreased in the C group (from 30.83 ± 1.85 at 20th minute to 29.0 ± 1.39ºC at 120th minute, and from 32.75 ± 0.96 to 31.05 ± 1.09ºC, respectively). Conclusion. The obtained results confirm that the external warming using warm air mattress was able to attenuate hypothermia, i.e. substantial decrease in core temperature, compared with the similar exposure to cold stress in the control group

Factors influencing antibiotic treatment cost and outcome in critically ill patients: A “real-life” study

Background/Aim. Critically ill patients are at very high risk of developing severe infections in intensive care units (ICUs). Procalcitonin (PCT) levels are eleveted in the circulation in patients with bacterial sepsis and PCT might be useful in guiding antibiotic treatment. The aim of this study was to estimate factors influencing patients survival and treatment cost in ICU with special emphasis on the impact of PCT serum levels use in guiding antimicrobial therapy. Methods. The study was conducted from August 2010 to May 2012 in the Intensive Therapy Unit, Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy (MMA), Belgrade, Serbia. All adult critically ill patients with sepsis and/or trauma admitted in the ICU were included in the study. This study included only the cost of antimicrobial therapy in the ICU and the cost for PCT analysis. We used prices valid in the MMA for the year 2012. PCT in serum was measured by homogeneous immunoassay on a Brahms Kryptor analyzer. Results. A total of 102 patients were enrolled. The mean patients age was 55 ± 19 years and 61.8% of patients were male. The mean length of stay (LOS) in the ICU was 12 ± 21 days. There was a statistically significant difference (p < 0.001) between the sepsis and trauma group regarding outcome (higher mortality rate was in the sepsis group, particularly in the patients with peritonitis who were mostly women). The patients younger than 70 years had better chance of survival. LOS, the use of carbapenems and PCT-measurement influenced the cost of therapy in the ICU. Conclusions. The obtained results show that age, the diagnosis and gender were the main predictors of survival of critically ill patients in the ICU. The cost of ICU stay was dependent on LOS, use of carbapenems and PCT measurement although the influence of these three factors on the outcome in the patients did not reach a statistical significance

Beta-lactam antibiotics use in intensive care units - the pathophysiological, pharmacokinetic, pharmacodynamic and pharmacoeconomic approach

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