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Background: The correct methodology of thrombelastography might be influenced by elapsing time. In our study we investigated kaolin activated citrated samples together with non-activated citrated samples in relation to the elapsed times of 0, 15 and 30 minutes to compare both methods and to find out if there is an impact of time on results of thrombelastography., Methods: Blood samples obtained from 10 healthy volunteers were analyzed after 0, 15 and 30 minutes from sampling with kaolin activation and without activation. Then the results were analysed and compared between the non-activated and the kaolin-activated method., Results: All blood samples became more hypercoagulable with the time elapsing, both in non-activated and kaolin-activated samples and differences between both groups were found statistically and clinically significant after only 0 minutes., Conclusions: The non-activated citrated method seems to be reliable and suitable for thrombelastography in non-emergency cases (planned surgical procedures) when we have time to wait 15-30 minutes to get results. In urgent situations a rapid thrombelastography test should be preferred. Although the kaolin-activated method can also be used, results must be interpreted with caution.

Introduction: Severe sepsis is still associated with significant morbidity and mortality, which is however different, as well as its management, depending on the region. What is the situation in the Czech Republic and what is the character of patients with severe sepsis is currently not known. The aim of the project is to describe the processes of care, outcome and characteristics of patients with severe sepsis admitted to the intensive care department of the Czech Republic., Methods: This is a multicentre and observational project with retrospective enrollment of patients who meet the criteria for severe sepsis before or within 24 hours after admission to selected intensive care units (ICU EPOSS)., Results: 394 patients were analyzed. Median age at admission was 66 (56- 76) years, males predominated (58.9%) and the median APACHE II score on admission was 25 (19- 32). Patients were predominantly medical (56.9%) and most were secondary admitted from other ICU (53.6%). Meeting the criteria of severe sepsis was most frequently within the period (± 4 hours) of admission the EPOSS ICU (77.6%). Median total fluid intake during the first 24 hours was 6,680 (4,840- 9,450) ml. Most patients required mechanical ventilation (58.4%). Compliance with the resuscitation bundle of severe sepsis in our group was very good and was associated with lower mortality of patients. Most frequently, the EPOSS ICU length of stay (LOS) was 7 (3- 15) days and median hospital LOS was 13 (8- 28) days. Hospital mortality in our cohort was 35.8%., Conclusion: Introducing the project, which in its first stage obtained valuable and internationally comparable data about patients with severe sepsis admitted to the involved ICU in the Czech Republic.

22 experts from the fields of gynecology and obstetrics, anesthesiology and resuscitation, intensive care, hematology and transfusion medicine has developed recommendations for diagnosis and procedure for life-threatening peripartum haemorrhage, which is still one of the most common causes of maternal mortality in childbirth. This guidelines, which is valid for the Czech Republic, supported by a total of 10 professional medical societies. There are based on new knowledge applicable at this time and is focused mainly on eliminating the most common causes of bleeding during delivery and prevention of haemorrhagic shock.

Background: Early diagnosis of sepsis and its differentiation from the noninfective SIRS is very important in order that treatment can be initiated in a timely and appropriate way. In this study we investigated standard haematological and biochemical parameters and thromboelastography (TEG) in patients who had undergone surgical resection of the oesophagus to find out if changes in any of these parameters could help in early differentiation between SIRS and sepsis development., Methods: We enrolled 43 patients (aged 41-74 years) of whom 38 were evaluable. Blood samples were obtained on the morning of surgery and then at 24-hour intervals for the next 6 days. Samples were analysed for procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL- 6), aspartate transaminase (AST), alanine transaminase (ALT) , lactate, white blood count (WBC), D-dimers, antithrombin (AT), international normalised ratio (INR), activated partial thromboplastin time (APTT) and parameters of TEG., Results: Significant differences between patients who developed sepsis during this period (9 patients) and SIRS were found in ALT on Day 1, in AST on Days 1-4, in PCT on Days 2-6; in CRP on Days 3-6; in IL-6 on Days 2-5; in leucocytes on Days 2, 3 and 6; and in D-dimers on Days 2 and 4. Significance values ranged from p < 0.0001 to p < 0.05., Conclusions: Sequential measurements of ALT, AST, PCT and IL-6 during the early postoperative period can be used for early differentiation of sepsis and postoperative SIRS after oesophagectomy. Among the coagulation parameters measured, only D-dimer concentrations appeared to be helpful in this process. TEG does not seem to be a useful early predictor of sepsis development; however it can be used to differentiate sepsis and SIRS from Day 5 after surgery.

Background and Purpose: Stimulation electromyography (sEMG) is useful in identifying the sphincter muscle (M) in patients with anorectal malformations (ARMs). This study evaluates the effect of anesthetic agents and M relaxants on sEMG findings., Materials and Methods: Seventeen infants (10 boys and 7 girls) with a mean age of 6.3 months and mean body weight of 6.7 kg were included in a prospective randomized study. Anesthesia was induced by sevoflurane and opioids, and an epidural catheter was inserted caudally. Stimulation electromyography of levator ani M using 14 mA current was used, and latency and amplitude of the evoked compound M action potential (CMAP) were recorded. Patients were randomized into 2 groups. Group A received a local anesthetic epidurally, and sEMG was performed. Administration of the M relaxant and measurement of M response followed. In group B drug administration, sEMG and response measurement were performed after administration of M relaxant., Results: Baseline CMAP was recorded in all patients. Average latency was 4.1 milliseconds, and average amplitude was 0.43 mV. In group A, the average latency was 4.0 milliseconds, and average amplitude was 0.65 mV. After administration of the M relaxant, the CMAP disappeared. In group B, no CMAP was observed immediately after administration of the M relaxant., Conclusion: Administration of the inhalational anesthetic, opioids, and local anesthetic did not influence the M response of M fibers in the levator ani M on sEMG and enables its localization during ARM reconstruction. Nondepolarizing M relaxation completely abolished the response. If M relaxant is necessary, cisatracurium is used. The most suitable method of anesthesia for ARM surgery appears to be inhalational anesthesia supplemented by opioids and epidural analgesia., (Copyright © 2011 Elsevier Inc. All rights reserved.)

In critically ill patients, either arterial or venous blood is usually available for sampling and measurement of basic coagulation parameters. The aim of this study was to examine whether in these patients the values of coagulation parameters differ significantly with respect to the source of the blood samples. In a group of 44 patients with severe sepsis, we compared the values of coagulation, thromboelastography and selected hematological parameters between the arterial and venous blood. In most of the investigated parameters (international normalized ratio, activated partial thromboplastin time, fibrinogen concentration, erythrocyte count, leukocyte and platelet count, hemoglobin level and thromboelastography parameters), we did not find significant differences (P > 0.1). However, we found a significantly lower antithrombin activity and a significantly higher D-dimer concentration in venous blood compared to arterial blood (P < 0.05). This could be associated with increased consumption of antithrombin and generation of D-dimer as a consequence of microthrombi formation in the capillaries. We therefore conclude that for the purpose of assessment of coagulation status in septic patients, arterial and venous blood cannot be treated as equivalent.

Heparin is commonly used to prevent obstruction of indwelling arterial catheters with blood clots. It is known to affect the outcomes of analysis of coagulation parameters with thromboelastography (TEG); therefore, it has been recommended to neutralize its effect with heparinase. However, heparinase may also neutralize the effect of low molecular weight heparin and endogenous heparinoids present in critically ill patients and thus yields unreliable results. The aim of this study was to evaluate the minimal discard blood volume needed to eliminate the effect of heparin flush on TEG parameters without the use of heparinase. Ten patients with indwelling arterial catheter were included in the study. Coagulation parameters were evaluated with kaolin-activated TEG. Blood samples were obtained after discarding 1, 2, 3, 4, 5 or 10 ml of blood to eliminate the effect of heparin. We investigated the influence of the discard volume on time until the first detectable clot (R), speed of clot development (alpha angle), maximal amplitude of the measured clot and time to maximal amplitude of the measured clot. We found an increase in coagulation (reflecting the heparin elimination) with the increasing discard volume between 1 and 4 ml. This was obvious from an increase in alpha angle and maximal amplitude of the measured clot and a decrease in R and time to maximal amplitude of the measured clot (P < 0.001). However, values obtained after discarding 4, 5 and 10 ml of blood did not differ markedly. To obtain valid information about TEG parameters, it is necessary to discard volume of at least 4 ml of blood (i.e., five times the volume of catheter dead space).

Beta-blockers are used for several decades also for the suppression of symptoms of the adrenergic stress in the perioperative period. While their benefit is considered indisputable there is no consensus on the most suitable patients' population where benefits would prevail over the risks most significantly. Present trends suggest the shift from the frequent widespread use to the more targeted medication, where the general status of the patient as well as the nature of the operation is being considered. Individual dose should be targeted to the specific therapeutic end-points. While the non-therapeutic use of beta-blockers by lay public is possible there is growing interest in their therapeutic use in severely septic patients. Favourable clinical experience results mostly from their use in the burned patients, where the natural course of the illness has many similarities with the protracted course of severe sepsis. Favourable influence of beta-blockers on monotonous tachycardia with minimal reflex variability of heart rate and on the resulting mortality has been demonstrated. Clinical experience has accumulated up to date reflecting the use of propranolol mostly; the experience with the more cardioselective beta-blockers is mostly experimental. Although there are legitimate worries about possible circulatory depression by beta-blockers empirical data do not support this. There are very encouraging data available about the favourable effect of beta-blockers on the outcome of the traumatised patients, especially patients suffering from a brain trauma.

Sternal dehiscence following cardiac surgery has a multifactorial etiology. Significant risk factors contributing to sternal dehiscence include chronic obstructive pulmonary disease (COPD), obesity, or re-exploration due to bleeding or pericardial tamponade. We have focused on the role of allogeneic blood transfusion as a factor leading to the poor healing of surgical wounds. A prospective observational study of 1553 elective and emergency cardiac surgery patients was performed between January 2003 and June 2007. All of the patients enrolled in this study underwent median sternotomy. We studied the relationship between sternal dehiscence following cardiac surgery and the total number of packed red blood cells transfused. The incidence of sternal dehiscence in the study group was 3.4%. Diabetic patients did not have a higher incidence of wound dehiscence. Although COPD, obesity, and re-exploration contributed to sternal dehiscence, the number of allogeneic blood transfusions during the perioperative period was an important independent risk factor for sternal dehiscence. Patients with sternal dehiscence received an average of 7.6 transfusion units (TU) of allogeneic blood versus 1.6 TU of allogeneic blood in the group without sternal dehiscence (P < 0.00005). The dehiscence affected patients without any other significant risk factor who received 6 or more TU, or patients with at least one significant risk factor who received 4 or more TU of allogeneic blood. According to our results, the total amount of allogeneic blood transfused is an important risk factor contributing to sternal dehiscence. Regardless of other risk preconditions, the transfusion of 6 or more TU could result in sternal dehiscence following cardiac surgery.

The aim of this retrospective study was to determine characteristic features of the onset and the course of the most severe forms of a severe acute pancreatitis with a concomittent multiorgan dysfunction syndrome. The study included patients transferred to the Intensive Care with a severe acute pancreatitis diagnosis and with a respiratory, circulatory and renal insufficiency or coagulopathy, or with the combination of the above. During the period from VII/1997 to XII/2002, 23 patients were treated. The mortality rate reached 78%. The average APACHE II score on admission was 23 in survivors, and 27 in no-survivors. Continuously high SOFA score (p < 0.05), more significant circulatory instability during the first days of the treatment, expressed by a higher need for the adrenaline use, and continuously increased CRP values during the follow-up treatment (day 7-14, p < 0.05), all of it signalized unfavourable results. In 50% of the fatal cases, renal insuficiency, requiring the use of the extracorporeal elimination method was reported while, on the other hand, none of the survivors suffered from renal insufficiency. The unfavourable course of the condition was also characterized by a need for more intensive therapies: those, who exited, had been cathetrized more often and they had required more surgical interventions. A favourable turn in the course of the disease was signalized by a drop in the serum CRP and by a decreasing need for vasopressors medication.

Postoperative pulmonary complications are of clinical importance: they prolong the hospitalization, increase the costs of treatment and contribute to the perioperative mortality. Respiratory insufficiency--inability to maintain adequate exchange of gases in the lungs--is its most severe form. Early diagnostics is essential and it is possible only during continuous and meticulous surveillance of the patient. In the postoperative period there are factors present enhancing the development of the postoperative pulmonary complications: drugs, pain, influence of the trauma of the operation, decreased lung capacity and decreased mobility. Prevention of complications is essential. Its indispensable part is adequate preoperative preparation, as well as good management of anaesthesia. The cornerstones of adequate postoperative care are oxygen therapy, sufficient analgesia, physiotherapy. At the earliest signs of respiratory insufficiency the commencement of respiratory support is mandatory. Artificial ventilation can be used as a preemptive measure preventing the development of pulmonary complications.

Background: Nitric oxide (NO) is a selective pulmonary vasodilator effective in the treatment of pulmonary hypertension and hypoxemic respiratory failure. Reports in the Czech literature on the results of its therapeutic use are still scarce., Methods and Results: Effects of inhaled NO on the changes of PaO2/FiO2 were assessed in the retrospective study. Records of artificially ventilated patients suffering from acute respiratory distress syndrome (ARDS) were reviewed. Daily highest NO dose, the highest PaO2/FiO2 ratio, duration of NO administration and death or survival of the patient was noted. Survivors and nonsurvivors, as well as responders (rise of PaO2/FiO2 by at least 20%) and non-responders were compared using Mann-Whitney and ANOVA test, alpha = 0.05. 16 patients were entered into the study, 13 (81%) responded positively to NO administration, the mortality was 56%. Comparing the age, NO dose, duration of its administration and APACHE II score in survivors and non-survivors, in respondents and non-respondents no differences were found. After NO administration the PaO2/FiO2 rose both in survivors and non-survivors (p < 0.0005). In survivors the response of oxygenation was more pronounced, although the difference did not reach the statistical significance (p = 0.07). On the days 1-3 the PaO2/FiO2 ratio was higher in survivors (p < 0.05)., Conclusions: Despite the transient increase in oxygenation after NO administration, mortality of patients with ARDS remained high. NO administration could not be considered the standard method of treatment of patients with ARDS in intensive care.

In cardiac surgical patients we investigated the effects of cardiopulmonary bypass (CPB) with a hollow fiber membrane oxygenator on blood clotting measured by thromboelastography (TEG). We found only a minimal change in the strength of blood clot described either by the TEG parameter MA (maximum amplitude) or by the shear modulus G calculated from MA. After CPB there was also a significant tendency towards hypercoagulation as defined by shortened parameters R, K and increased a-angle. After comparison with published data obtained in cardiac surgical patients using a bubble oxygenator we conclude that currently used extracorporeal technology exerts a less negative influence on blood clotting than had been conceived previously.

Purpose of the Study: Aprotinin is a non-specific inhibitor of serine proteases with hemostyptic and hemostatic properties. The effect covers suppression of fibrinolysis and support of the role of thrombocytes in coagulation. In a prospective randomized study we verified whether the application of aprotinin (Antilysin Spofa, Czech Republic) in the dosage effective in cardiosurgical patients reduces blood loss and the need for blood transfusion for orthopaedic patients., Material: 42 patients indicated to the primary THA were randomly selected into the study and control groups. Excluded were allergic patients and those who used aprotinin before., Methods: Administration of 2.10(6) KIU of aprotinin was started preoperatively and is continued in the course of the first hour of surgery. In the operated on patients we recorded prior to operation and in the first post-operative morning the level of hemoglobin in blood and hematocrit, the number of infusions and blood transfusion units administered in the course of the surgery and in the post-operative period until the first post-operative morning. We recorded blood loss in the period between the surgery and the first post-operative morning. Data acquired in the patients of the studied and control groups were compared by means of ANOVA test for repeated measuring and with the use of Mann-Whitney and chi 2-test, the level of significance p < or = 0.05. During the hospitalization we the patients were checked for symptoms of deep venous trombosis and tromboembolic or other adverse events., Results: Hemoglobinemia and hematocrit in both groups significantly decreased after the operation (p < 0.0005), the differences between the studied and control groups were not significant. The number of administered blood units did not differ in the examined and control groups. The frequency of blood transfusions was postoperatively higher in the control group (59.1% as compared to 30%), however, the difference was not statistically significant (p = 0.059). Blood loss in the post-operative period was higher in the control group (p = 0.048). Patients from the control group got in total blood transfusion more frequently (p = 0.032). Differences in the total frequency of blood transfusion and in the amount of post-operative blood loss were statistically significant. In the course of hospitalisation no signs of deep phlebothrombosis or thromboembolic condition were encountered in either group of patients. Complications were not recorded., Discussion: Our results correspond with most of the published data. Blood loss of the operated on patients who were administered prior to and at the beginning of the operation in total 2.10(6) KIU of aprotinin (Antilysin Spofa) in infusion was on average by 33% less in the post-operative period and in the whole peropetive period they required less frequently blood transfusion (40% vs 73%)., Conclusion: Infusion of aprotinin (Antilysin Spofa) in the dosage of the order of 106 KIU significantly reduces post-operative blood loss and frequency of transfusion in the peroperative period in patients undergoing THA.

Gastric or intestinal luminal tonometry is a method for monitoring critically ill patients. It offers an index of the adequacy of aerobic metabolism in a tissue that is particularly sensitive to alterations in its perfusion and oxygenation: the gut mucosa. It is based on the measuring the increase in tissue CO2 production that accompanies anaerobic metabolism. The method simply consists of a balloon in the stomach, which measures intramucosal pCO2. From this measurement and from the arterial bicarbonate concentration gastric intramucosal pH (pHi) can be calculated, assuming that bicarbonate concentration in the gastric mucosal tissue is in equilibrium with systemic arterial bicarbonate. Despite possible clinical benefit from the measurement and the therapy of low pHi values in critically ill patients, the theoretical, experimental and pathophysiological implications for the monitoring of intramucosal acidosis in the gut are not yet fully understood. There are still some open methodological questions crucial for further clinical interpretation.

The authors present the case of successfully treated patient with CAD, operated from left anterolateral minithoracotomy. Angiographic control two years later presents fully patent anastomosis without any signs of stenosis.

Methods and Results: From the group of 110 neonates born with transposition of the great arteries during 1991-1994 that were referred for the treatment to Kardiocentrum, University Hospital Prague-Motol, 46 neonates with simple transposition were operated on according to the criteria for anatomical correction (arterial switch) at the mean age of 9 days (4-20 days). Fourteen infants with transposition and large ventricular septal defect were corrected with arterial switch at the mean age of 2.5 months (5 weeks-9 months). Fifty neonates that did not meet criteria for arterial switch procedure were indicated for correction at the atrial level (Senning procedure) that has been performed at the mean age of 5 months (1-10 months). Out of 46 operated neonates 10 died following the operation and one child died 2 months later after surgery. There were 2 death out of last 20 neonates (10%). Thirty five children surviving 1-4 years after anatomical arterial correction of transposition are without complaints in excellent condition, NYHA class I., Conclusions: The procedure of the anatomical correction at the level of the great arteries (arterial switch) according to Jatene, that has been successfully introduced at Kardiocentrum, University Hospital Prague-Motol, has been reproducible and became the method of choice for operations of transposition of the great arteries in neonates with the suitable anatomy.

The authors give an account of 16 cases where they used the right gastroepiploic artery (GEA) for revascularization of the heart muscle. Their own findings are based on the author's experience at a department with the greatest number of thus operated patients (Groningen, Netherlands). These data were already published. GEA was used during the revascularization operation in 16 of 112 patients operated after 1994 (14%). All operated patients were males aged 30 to 58 years (mean age 47 years). None of the patients died. The use of GEA did not cause any postoperative complications. During the short-term follow up there was no reason to doubt the patency of the graft and an invasive examination was not indicated so far. According to the authors' experience the GEA graft can be used for anastomosis with the right coronary artery or its branch almost in all patients indicated for revascularization. It is thus possible to obtain a high-standard arterial graft where long-term patency can be assumed. The authors discuss in detail the indications and technique of the operation.

During 47 re-operations on the open heart the authors used the method of autotransfusion, predeposition of the patient's blood and intravenous administration of aprotinin to reduce postoperative haemorrhage and blood consumption. The patients were classified according to the methods or their combinations used into three groups and the authors compared, using statistical methods the blood losses, blood consumption, haemolysis, renal function and the effect of the methods used on the morbidity. The results were compared with a control group where the mentioned methods of economizing on blood were not used. The authors recorded significantly higher haematocrit values in all three groups where economic methods were used at the end of the extracorporeal circulation (EC), as compared with the control group. The volume of the administered blood transfusion was significantly lower in group 1 where an autotransfusion apparatus Cell saver was used. The volume of the administered blood transfusion in the other groups did not differ when evaluated by statistical methods. The filling of the apparatus for extracorporeal circulation was blood free in 90% in group 1, in 75% in group 2, in 92.2% in group 3 and in 75% in the control group. Blood losses via thoracic drains did not differ significantly in different groups though there was a wide range of recorded values. In both groups 2 and 3 where patients were given aprotinin haemoglobinuria was more frequent, as confirmed by laboratory tests. The authors observed also a greater diuresis, without laboratory evidence of impairment of renal function.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomical correction with an intraventricular tunnel, as suggested by Kawashima, was performed in 14 children with a double-outlet right ventricle and a subpulmonary (4) or non-committed (10) defect of the ventricular septum with one early and one late death. Nine children had previous palliative operations. Complications after radical surgery were residual ventricular defects (4), infectious endocarditis (2) and impaired rhythm (one sudden death). Twelve patients are after medium- term or long-term follow-up free from subjective complaints, ten children report good performance, in two the performance is slightly reduced. Anatomical intraventricular correction of double-outlet right ventricle restores the mitral valve and left ventricle to the systemic circulation. The prognosis of children with double-outlet right ventricle and subpulmonary or remote ventricular defect improves substantially.

Four children with double outlet right ventricle type Taussig-Bing were operated in 1988-1990 by anatomical correction-arterial switch. Primary correction of the defect was performed in one infant at the age of three months. Three children had a previous palliative operation (banding of the pulmonary artery, resection of coarctation of the aorta and ductus arteriosus). Anatomical correction of the defect was performed in a second stage at the age of 14, 15 and 19 months. One child died from Gram-negative septicaemia on the 8th day after operation. Three children are completely free from complaints and develop normally. The authors discuss some technical aspects of the arterial switch operation in infants with double outlet right ventricle.