Search

Ventilator-associated pneumonia (VAP), one of the most common healthcare-associated infections in intensive care settings, is associated with significant morbidity and mortality. VAP is diagnosed in >10% of patients on mechanical ventilation, incidence rising with number of ventilator days. In recent decades, the pathophysiology of VAP, VAP risk factors and treatment have been extensively studied. In critically ill pediatric patients, mechanical issues such as insufficient tightness of the ventilator circuit (mainly due to historically based preference of uncuffed tubes) and excessive humidity in the circuit are both significant risk factors of VAP development. Protocol-based approaches to critically ill patients on mechanical ventilation, closed suctioning, upper body position, enteral feeding and selective gastric acid suppression medication have a beneficial effect on VAP incidence. In recent decades, cuffed tubes applied to the whole spectrum of critically ill pediatric patients (except neonates <2700 g of weight), together with cuff-oriented nursing care including proper cuff-pressure (<20 cm H2O) management and the use of specialized tracheal tubes with subglottic suction ports combined with close infraglottic tracheal suctioning, have been implemented. The aim of this review was to summarize the current evidence-based knowledge about the pathophysiology, risk factors, diagnosis, treatment and prevention of VAP in clinically oriented settings.

Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.

Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.

Importance: Multiple sclerosis can also affect children. Approximately 3-10% of patients develop multiple sclerosis before the age of 16., Objective: The aim of this analysis is to describe the characteristics of pediatric patients with multiple sclerosis who started their treatment with disease-modifying drugs in 2013-2020, with data obtained from the Czech National Registry of patients with multiple sclerosis., Design and Setting: A method of retrospective analysis conducted with 134 pediatric patients with multiple sclerosis was used., Results: The findings reveal that the mean age at the date of the introduction of the first disease-modifying drugs treatment is 15.89 years, and gender does not play any role. In addition, moderate (51.6%) and mild (45.2%) relapses are predominant in these young patients. Seventy five percent of patients will not experience a confirmed progression of the expanded disability status scale within 54.7 months from starting the treatment. Furthermore, the results confirm that the first-choice treatment is interferon beta-a and glatiramer acetate, which is common for adult patients. However, some factors, such as a low efficacy or a lack of tolerance may impact on treatment discontinuation in children., Conclusion: More research should be performed on novel disease-modifying drugs for this target group., Competing Interests: MVac was employed by KZ a.s., Hospital Teplice. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Vališ, Pavelek, Novotný, Klímová, Šarláková, Halúsková, Peterka, Štětkárová, Štourač, Mareš, Hradílek, Ampapa, Vachová, Recmanová and Meluzínová.)

In December 2019 SARS-CoV-2 initiated a worldwide COVID-19 pandemic, which is still ongoing in 2022. Although adult elderly patients with chronic preexisting diseases had been identified as the most vulnerable group, COVID-19 has also had a significant impact on pediatric intensive care. Early in 2020, a new disease presentation, multisystemic inflammatory syndrome, was described in children. Despite the vaccination that is available for all age categories, due to its selection process, new viral mutations and highly variable vaccination rate, COVID-19 remains a significant clinical challenge in adult and pediatric intensive care in 2022.

The clinical course of the SARS-CoV-2 virus infection (COVID-19 disease) in paediatric patients is predominantly mild. However, in a small percentage of paediatric patients, the COVID-19 could lead to the development of with the Paediatric Inflammatory Multisystem Syndrome (PIMS) presenting as high fever, gastrointestinal symptoms, neurological symptomatology and even as multiorgan dysfunction. These three cases represent the first published report of critically ill paediatric patients with PIMS in the Czech Republic.

We present the case report of an unvaccinated Czech child with tetanus. The child had not received any vaccines due to its parent's refusal. The disease originated from the wound in the nose caused by a small flat battery. The typical onset of tetanus followed after two weeks, rapidly progressing to respiratory failure with the need for mechanic ventilation despite intensive treatment. The child spent five weeks in the hospital. Mild long-term sequelae persisted 5 months.

Background: The indirect visualisation of the glottic area with a videolaryngoscope could improve intubation conditions which may possibly lead to a higher success rate of the first intubation attempt., Objective: Comparison of videolaryngoscopy and direct laryngoscopy for elective airway management in paediatric patients., Design: Prospective randomised controlled trial., Settings: Operating room., Participants: 535 paediatric patients undergoing elective anaesthesia with tracheal intubation. 501 patients were included in the final analysis., Interventions: Patients were randomly allocated to the videolaryngoscopy group (n  = 265) and to the direct laryngoscopy group (n  = 269) for the primary airway management., Main Outcome Measures: The first attempt intubation success rate was assessed as the primary outcome. The secondary outcomes were defined as: the time to successful intubation (time to the first EtCO2 wave), the overall intubation success rate, the number of intubation attempts, the incidence of complications, and the impact of the length of the operator's clinical practice., Results: The study was terminated after the planned interim analysis for futility. There were no significant demographic differences between the two groups. The first attempt intubation success rate was lower in the videolaryngoscopy group; 86.8% (n  = 211) vs. 92.6% (n  = 239), P = 0.046. The mean time to the first EtCO2 wave was longer in the videolaryngoscopy group at 39.0 s ± 36.7 compared to the direct laryngoscopy group, 23.6 s ± 24.7 (P < 0.001). There was no difference in the overall intubation success rate, in the incidence of complications nor significant difference based on the length of the clinical practice of the operator., Conclusions: The first attempt intubation success rate was lower in the videolaryngoscopy group in comparison to the direct laryngoscopy group. The time needed for successful intubation with videolaryngoscopy was longer compared with direct laryngoscopy., Trial Registration: Clinicaltrials.gov identifier: NCT03747250., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.)

Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging-MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.

Importance: Postoperative bleeding is a common and potentially life-threatening complication. Precise identification of risk factors in addition to the basic ones, such as coagulation parameters, is certainly very desirable., Objective: The aim of this study was to identify other possible risk factors for bleeding after adenoidectomy in children., Design: This observational prospective study enrolled children undergoing adenoidectomy from October 2019 to February 2020, then evaluated the influence of possible risk factors for bleeding., Setting: Tertiary pediatric otorhinolaryngology center., Participants: A total of 288 children aged 0-18 years undergoing adenoidectomy for recurrent upper respiratory tract infections, recurrent acute otitis media, secretory otitis media, and obstructive sleep apnea syndrome., Main Outcomes and Measures: Increased blood pressure and time of surgery were identified as risk factors for bleeding after adenoidectomy., Results: Elevated systolic ( p = 0.046), diastolic ( p = 0.012), and mean arterial blood pressure ( p = 0.007) (Mann-Whitney U test) as adjusted for age-specific distributions and with corrections for height and weight, as well as time length of surgery ( p < 0.001) (Fisher's exact test) were revealed as statistically significant risk factors for postoperative bleeding. Atmospheric pressure, surgeon's level of experiences, chronic inflammatory content in adenoid vegetation (AV), size of AV, recidivism of AV, recurrent infections of the upper respiratory tract, type of anesthesia, long-term using of drugs, and positive coagulation questionnaire or pathology in standard coagulation tests were not found to be risk factors for bleeding after adenoidectomy., Conclusions and Relevance: In this prospective study within a well-defined population of children, we evaluated increased blood pressure and time of surgery as risk factors for bleeding after adenoidectomy. These data bring new information that complements current knowledge in this field.

Objectives: The presented study aimed to describe the dynamics of the serum levels of the complement components C3, C4, and C1 inhibitor in women immediately before and after giving birth by caesarean section (CS)., Design and Setting: 57 pregnant women undergoing caesarean section were included in this prospective observational study. Blood samples were taken 30 minutes before CS and 30 minutes after the delivery. C3, C4, and C1 inhibitor levels were analysed and the functional C1 inhibitor test performed. Angiotensin-converting enzyme concentrations before delivery were also determined., Results: Before delivery, C3 value was elevated above the reference limits for the healthy adult population in 39% of patients. Following birth, C3 median value dropped from 1.4 to 1.2 g/L. C1 inhibitor concentrations were also reduced - the median value of the C1 inhibitor before the birth was 222 mg/L, dropping to 198 mg/L after delivery. Even before the CS, C1 inhibitor concentrations were below reference range in 40% of patients, which increased to 56% after delivery; its activity however did not significantly change. In two patients with perioperative uterine hypotonia, notable complement activation was detected. ACE levels were below the normative values for adult population in 25% of patients., Conclusion: Concentrations of all analysed components significantly decreased after delivery, which was not associated with blood loss or amount of intravenous liquids. This highlights the necessity of proper reporting of the time point of blood sampling in any studies or case reports detailing the immunological condition of patients in the peripartal period.

Background: Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system. Well-established drugs used for MS patients after the first demyelinating event in the Czech Republic include glatiramer acetate (GA), interferon beta-1a (IFNβ-1a), IFN beta-1b (IFNβ-1b), peginterferon beta-1a (peg-IFNβ-1a), and teriflunomide. Objective: The objective of this observational study was to compare the effectiveness of the abovementioned drugs in patients with MS who initiated their therapy after the first demyelinating event. Patients were followed for up to 2 years in real clinical practice in the Czech Republic. Methods: A total of 1,654 MS patients treated after the first demyelinating event and followed up for 2 years were enrolled. Evaluation parameters (endpoints) included the annualized relapse rate (ARR), time to next relapse, change in the Expanded Disability Status Scale (EDSS) score, and time of confirmed disease progression (CDP). When patients ended the therapy before the observational period, the reason for ending the therapy among different treatments was compared. Results: No significant difference was found among the groups of patients treated with IFNβ-1a/1b, GA, or teriflunomide for the following parameters: time to the first relapse, change in the EDSS score, and the proportion of patients with CDP. Compared to IFNβ-1a (44 mcg), a significant increase in the percentage of relapse-free patients was found for GA, but this treatment effect was not confirmed by the validation analysis. Compared to the other drugs, there was a significant difference in the reasons for terminating GA therapy. Conclusion: Small differences were found among GA, IFNβ and teriflunomide therapies, with no significant impact on the final outcome after 2 years. Therefore, in clinical practice, we recommend choosing the drug based on individual potential risk from long-term therapy and on patient preferences and clinical characteristics., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Pavelek, Sobíšek, Šarláková, Potužník, Peterka, Štětkárová, Štourač, Mareš, Hradílek, Ampapa, Grünermelová, Vachová, Recmanová, Angelucci, Halúsková and Vališ.)

Out-of-hospital cardiac arrest in pediatric population is rare and predominantly has respiratory aetiology. Authors present the relatively unique case of out-of hospital cardiac arrest in 5-years old pediatric patient due to ventricular fibrillation (VF) as the initial rhythm during the advanced life support. The patient was resuscitated by his parents and the initial rhythm was VF. After defibrillation the patient was admitted to the pediatric intensive care were another two episodes of VF was detected and treated. After standard postresuscitation care, patient was weaned from sedation and extubated with good neurologic outcome. Genetic screening of the 7 genes associated with cardiac channelopathies (KCNQ1, KCNH2, SCN5A, KCNE1, KCNE2, RYR2, CASQ2) found mutation in gene KCHN2 and gene SCN5A, that were according to actual data considered benign. This case highlights the need for automated external defibrillator implementation in basic life support also in pediatric population and possible role of genetic predisposition in emergence of fibrillation.

Progressive multifocal leukoencephalopathy (PML) is a severe disease of the central nervous system with very high mortality. It is caused by the JC virus with high seroprevalence, at up to 80%. Development of PML is typically opportunistic, particularly in acquired immunodeficiency syndrome, and usually affects patients with profound immunodeficiency. Furthermore, as a result of highly efficient immunosuppressive and immunomodulatory treatments in recent years, the number of PML cases has increased in the general population. In this article, the authors mention virological and epidemiological relationships and characteristic manifestations of PML. Possible relationships of humoral and cellular immunity are discussed and limited treatment options including prophylaxis are mentioned.

Objectives: Multiple sclerosis (MS) often occurs in young women and the effect of obstetric anesthesia/analgesia on the disease is poorly understood. No previous study has investigated the course of the disease in women in labor in the Czech Republic. The aim of this study was to evaluate the occurrence or absence of relapses in the 6-month postpartum period in MS parturients with and without obstetric anesthesia/analgesia., Materials and Methods: We retrospectively studied all deliveries (n = 58,455) at the University Hospital Brno from 2004 to 2013 and identified those of the women with an ICD-10 code G35 (MS) recorded anytime in their medical history (n = 428). We included only deliveries of women with confirmed diagnosis at the time of labor (n = 70). Statistical analysis was performed using the Fischer Exact Test., Results: There were 70 deliveries of 65 women, including 45 vaginal deliveries and 25 Cesarean deliveries (16 under general anesthesia, 8 with epidural anesthesia and 1 with spinal anesthesia). Epidural obstetric analgesia was performed in 11 deliveries. There was no statistically significant difference in relapses between the vaginal delivery group (n = 15; 33%) and Cesarean section group (n = 10; 40%), p = 0.611., Conclusion: Neither delivery mode (vaginal vs Caesarean) nor type of obstetric anesthesia/analgesia was found to have any impact on the course of MS at 6 months postpartum in women with this condition., (© 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Purpose: To evaluate the impact of MR gradient system imperfections and limitations for the quantitative mapping of short T2* signals performed by ultrashort echo time (UTE) acquisition approach., Materials and Methods: The measurement of short T2* signals from a phantom and a healthy volunteer study (8 subjects of average age 28 ± 4 years) were performed on a 3T scanner. The characteristics of the gradient system were obtained using calibration method performed directly on the measured subject or phantom. This information was used to calculate the actual sampling trajectory with the help of a parametric eddy current model. The actual sample positions were used to reconstruct corrected images and compared with uncorrected data., Results: Comparison of both approaches, i.e., without and with correction of k-space sampling trajectories revealed substantial improvement when correction was applied. The phantom experiments demonstrate substantial in-plane signal intensity variations for uncorrected sampling trajectories. In the case of the volunteer study, this led to significant differences in relative proton density (RPD) estimation between the uncorrected and corrected data (P = 0.0117 by Wilcoxon matched-pairs test) and provides for about ~15% higher values for short T2* components of white matter (WM) in the case of uncorrected images., Conclusion: The imperfection of the applied gradients could induce errors in k-space data sampling which further propagates into the fidelity of the UTE images and jeopardizes precision of quantification. However, the study proved that measurement of gradient errors together with correction of sample positions can contribute to increased accuracy and unbiased characterization of short T2* signals., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Comparison of incisional and epidural analgesia in the treatment of postoperative pain after cesarean sectio., Design: Prospective cohort study in the period from 2015 to 2016., Setting: Department of Obstetric and Gynecology, Masaryk University, University Hospital Brno., Material and Methods: The group included 72 patients in the 38th-41st. week of pregnancy. They were divided at the time of indication to the cesarean section (SC) into two groups according to the selected type of analgesia (epidural/incisional). Women with epidural analgesia (EA) received bupivacaine and sufentanil after surgery in the epidural catheter. A second group was patients during general anesthesia SC introduced into the surgical wound IA Painfusor which was continuously administered bupivacaine. The intensity of the patients pain was evaluated on the visual analogue scale (VAS). If the VAS exceeded 4, the dose of the opioid analgesic piritramide (additional dose of DDA analgesic) was administered intravenously. The intensity of pain and the number of DDAs required were evaluated 24 hours after SC. Satisfaction with pain relief, sleep quality, and patient side effects were assessed using a questionnaire., Results: Patients in the EA group (n = 36) evaluated postoperative pain (PB) value of 4.4 ± 1.8 according to VAS, women in group IA (n = 36) reported a PB according to VAS of 4.4 ± 1.3 (p = 0.972). The difference in the number of applied DDA was not statistically significant compared groups (2.3 ± 0.9 EA vs. 2.4 ± 0.9 IA, p = 0.301). By comparing the other parameters evaluated by the questionnaire statistically significant more vertigo cases were found in women with IA (22.2% EA vs. 72.2% IA, p &lt; 0.001). In the other evaluated parameters the differences between the two methods were not statistically significant., Conclusion: Epidural and incisional analgesia are comparable methods in the effectiveness of pain management during the first day of the cesarean section. Except for vertigo, both methods were also comparable in terms of the occurrence of undesirable effects.

This paper presents the domain of information sciences, applied informatics and biomedical engineering, proposing to develop methods for an automated detection of similarities between two particular virtual learning environments - virtual patients at Akutne.cz and the OPTIMED curriculum management system - in order to provide support to clinically oriented stages of medical and healthcare studies. For this purpose, the authors used large amounts of text-based data collected by the system for mapping medical curricula and through the system for virtual patient authoring and delivery. The proposed text-mining algorithm for an automated detection of links between content entities of these systems has been successfully implemented by the means of a web-based toolbox.

Goal of the Study: The aim of national survey was to describe current practice for analgesia during labour provided by anaesthesiologists in the Czech Republic (CZE)., Type of the Study: National prospective observational., Setting: 49 obstetric departments in CZE., Methods: We aimed to enrol all 97 obstetric departments in CZE and to monitor every case of anaesthetic care in peripartum period during November 2011. Data were recorded to Case Report Form with two parts (Demography 2010 and Case Report) into TrialDB database (Yale University, USA; adapted IBA, MU, CZE). Demographic data for CZE were obtained on request by ÚZIS. The data were analysed using SPSS 22., Results: We enrolled 1943 cases of anaesthesiological care and 579 (29.8%) of them was to relief labour pain. Population and center weighted estimate of incidence of epidural labour analgesia was 12.5% (95% CI: 10.6% - 14.4%). Epidural analgesia was the most frequently applied via Tuohy needle G18 (97.8%), with administration of an epidural catheter G20 (95.7%), via medial approach (98.8%), in lateral position (76.7%) by the loss of resistance method (94.3%). All administrations of epidural analgesia were started by initial bolus, only in 28.2% of cases were followed continously. Always has been applied mixture of local anaesthetic with sufentanil at a dose of 3-10 mcg. Bupivacaine was most frequently used local anaesthetic (80.7%), followed by levobupivacaine (12.6%). Median concentrations both bupivacaine and levobupivacaine were 0.125% (min. 0.1%, max. 0.3%).The most common complication of epidural analgesia was repeated puncture (21.2%), blood in the catheter (1.4%), blood in the needle (1.2%), unintended puncture of the dura mater (0.7%) and transient paresthesias (0.5%)., Conclusion: In comparison to previously published data there was trend for lower incidence of epidural analgesia for labour in the CZE.

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

Purpose of the Study: The primary objective of the study was to find out in-hospital mortality in patients undergoing surgery for proximal femoral fracture. The secondary objective was to identify independent predictors of in-hospital mortality., Material and Methods: A retrospective single-centre observational study PROXIMORT of patients operated on for isolated proximal femoral fracture at the University Hospital (FN) Brno in the years 2011 and 2012. The 30-day and overall one-year mortality in the study group and the impact of observed parameters on mortality were also assessed. The observed parameters were: patient age and sex, ASA score, time from injury to surgery (hr), daily (7-20 hr) or night (20-7 hr) time of surgery, type of anaesthesia (general vs spinal), initial haemoglobin and haematocrit levels, intra-operative administration of blood products and vasopressors, and erudition of the anaesthesiologist and surgeon. To evaluate the relationship of in-hospital mortality to the observed characteristics, we used univariate logistic regression modelling and odds ratio, using SPSS 22 software (IBM, USA)., Results: Data were obtained from 414 patients and 369 patients were included (male, n = 91; female, n = 278). Due to exclusion criteria, 45 patients were excluded (not an isolated injury). In-hospital mortality was 6.5% (n = 24), 30-day mortality was 8.4% (n = 31) and total mortality of the study group was 35.8% (n = 132). Statistically significant effects on in-hospital mortality included: older age of the patient (p = 0.013), ASA score of 3 or more (p = 0.002) and general anaesthesia administration (p = 0.043). For 30-day mortality, this was older age (p = 0.012), ASA score of 3 and more (p < 0.001), general anaesthesia administration (p < 0.001), lower weight (p = 0.028), lower BMI (p = 0.006) and intra-operative administration of vasopressors (p = 0.023). The influence of other observed parameters on post-operative mortality was not statistically significant., Discussion: In-hospital mortality in the PROXIMORT study was 6.5% (95% confidence interval (CI) 4.2 to 9.5%), which was significantly higher than in-hospital mortality in unselected surgically treated patients in the Czech Republic, as reported in the EuSOS study (2.3% with 95% CI 0.9 to 3.7%). Administration of general anaesthesia was determined as an independent predictor of in-hospital and 30-day mortality, which was concordant with the results of meta-analysis published by Rodgers et al. and Barbosa et al in 2013. Postponing surgery for perioperative optimisation had no effect on mortality according to the PROXIMORT study. Patorn et al. have supported this conclusion by the results of a selected group of patients with surgery delayed for more than 24 hours; the patients mortality, regardless of anaesthesia, was up to 2.5%., Conclusions: The PROXIMORT study identified the higher patient age, ASA score of 3 and more and general anaesthesia administration as independent predictors of in-hospital mortality.