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Copyright of Anaesthesiology & Intensive Medicine / Anesteziologie a Intenzivní Medicína is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Mucormycosis is a very serious, invasive fungal infection, occurring frequently in patients with a modified immune response. Mortality in cases of a generalized form of mucormycosis can reach 96 %. The principles of successful treatment of this disease are early diagnosis and aggressive antimycotic and/or surgical therapy. In this case report we point out the clinical importance of correct timing of therapy, even though even early and appropriate management does not always guarantee survival. [ABSTRACT FROM AUTHOR]

Solid organ transplantation is the only way to treat end-stage organ disease. Survival of the patients with a transplanted organ has improved significantly in the last decades. It has been mainly due to the careful selection of organ transplant candidates from the waiting lists, improved surgical techniques and advances in intensive care and immunosuppressive therapy. This has logically led to an increase in the number of these patients on the follow-up, treated in the emergency departments and admitted to hospitals and intensive care units. The anaesthetic and intensive care management of the transplant recipients is similar to standard practice but there are physiological and pharmacological specific aspects including the adverse effects of immunosuppression, the risk of infection and the risk of rejection which the anaesthetist and the intensivist should consider. One of the most common reasons for hospital admission of the transplanted patients is infection and sepsis, the most common cause of morbidity and mortality in these patients. The cornerstones in the treatment of sepsis are early pathogen identification, infection source control and supportive therapy including temporary withdrawal of the immunosuppressive therapy. [ABSTRACT FROM AUTHOR]

Copyright of Anaesthesiology & Intensive Medicine / Anesteziologie a Intenzivní Medicína is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Ingestion of Amanita phalloides is the most common cause of fatal mushroom poisoning. The clinical picture of intoxication varies from mild subclinical manifestation to lethal fulminant course with the development of acute liver failure. Early diagnosis of Amanita phalloides poisoning is crucial for the outcome but i tis difficult because it is often mistaken as gastroenteritis or due to other mushroom poisoning. The diagnosis is based on the history of recent mushroom ingestion followed by gastrointestinal symptoms, typical time course and laboratory markers and is proven with mycological examination or toxicological examination. Specific treatment consists of detoxification procedures, supportive measures, administration of drugs and therapy in the specialized intensive care unit in the case of acute liver failure. In selected patients with acute liver failure urgent liver transplantation is the only life-saving option.

Sepsis biomarkers change continuously during the postoperative period. We aimed to demonstrate the influence of immunosuppressants after transplantation (Tx) on presepsin, procalcitonin, CRP, white blood cells, and IL-6. A group of 140 patients after major surgery (86 non-Tx, 54 Tx) without any signs of sepsis or infectious complications was followed for 7 days. The changes in biomarkers were analyzed with respect to the type of surgery, organ, and induction immunosuppressant used (antithymocyte globulin, corticosteroids, or basiliximab/rituximab). Concentrations (95th percentiles) of presepsin and procalcitonin were higher in the Tx group (presepsin: Tx < 2380 vs. non-Tx < 1368 ng/L, p < 0.05; procalcitonin: <28.0 vs. 3.49  μ g/L, p < 0.05). In contrast, CRP and IL-6 were lower in the Tx group (CRP: Tx < 84.2 vs. non-Tx < 229 mg/L, p < 0.05; IL-6: <71.2 vs. 317 ng/L, p < 0.05). Decreases in CRP and IL-6 were found for all immunosuppressants, and procalcitonin was increased after antithymocyte globulin and corticosteroids. Negligible changes were found for white blood cells. Different responses of presepsin, procalcitonin, CRP, and IL-6 were therefore found in patients without any infectious complications after major surgery or transplantation. Immunosuppression decreased significantly IL-6 and CRP in comparison to non-Tx patients, while procalcitonin was increased after corticosteroids and antithymocyte globulin only. Cautious interpretation of sepsis biomarkers is needed in the early posttransplant period. This work was conducted as a noninterventional (nonregistered) study., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2021 Janka Franeková et al.)

Introduction: Endoscopic pyloromyotomy (G-POEM) is an emerging therapeutic method for the treatment of gastroparesis (GP). So far, only limited case-series suggesting its effectivity have been published. The aim of our study was to assess the effectivity of G-POEM in patients with refractory GP., Methods: Consecutive patients with severe and refractory GP were offered the procedure. An abnormal gastric emptying study (GES) was necessary for inclusion. The main outcome was treatment success defined as a decrease of the total GSCI symptom score by at least 40% from baseline at 3, 6, 12 and 24 months., Results: G-POEM was performed in 9 patients (5 women, mean age 56.3): 5 post-surgical, 2 diabetic, 1 idiopathic and 1 combined post-surgical and diabetic. The median follow-up was 23M (range 12-31). All procedures were successfully completed. One patient experienced delayed bleeding from gastric ulceration, which was successfully treated endoscopically; all remaining patients recovered uneventfully. Treatment success was achieved in 8/9 patients (88.9%) at 3, 6 and 12M and in 3/4 (75%) at 24M. The mean GSCI decreased from 3.16 to 0.86 (p=0.008), 0.74 (p=0.008), 1.07 (p=0.008) and 1.31 (p=0.11) at 3, 6, 12 and 24M after the procedure. The Quality of Life Index improved from the baseline value of 77 (range 48102) to 113 (86-138, p=0.03) and 96 (50-124, p=0.4) at 12 and 24M. In patients with treatment success, no recurrences have occurred so far. GES improved/normalized in all the patients., Conclusion: G-POEM was effective in 88.9% of patients with refractory GP and the effect seems to be long-lasting.

Introduction: Liver transplantation is established as a lifesaving procedure for patients with acute and chronic liver failure, as well as certain selected malignancies. Due to a continuing organ shortage and ever-growing patient waiting lists, donation after cardiac death (DCD) is becoming more frequently utilized in order to close the gap between &#8220;supply and demand&#8221;., Methods: A retrospective analysis of DCD and subsequent liver transplantations was performed., Results: From May 2016 to September 2019, a total of 9 DCD liver transplantations were performed in our institution. All cases except one were primary liver transplantations. The recipients comprised 5 (56%) males and 4 (44%) females. The mean DCD donor age was 41±12 (22-57) years, with ventilation duration of 7±1 days and warm ischemia time 19±3 minutes. The average recipient age was 51±22 (4-73) years, with an average cold ischemia 3h:59m±27m and manipulation time of 23±5 minutes. Periprocedural mortality was 1 (11%). Hepatitis C recurrence was documented in 1 (11%) patient. The mean follow-up time was 19±13 (7-37) months. Until now, we have not observed any signs of ischemic cholangiopathy., Conclusion: DCD liver transplantation allows us to enlarge the pool of potential liver grafts, thus decreasing the time spent on the liver recipient waiting list. This paper documents the first series of DCD liver transplantations in the Czech Republic.

The prevalence of liver cirrhosis in population is increasing, as well as its prevalence among patients admitted to hospital for elective surgery. These patients are at risk of high postoperative morbidity and mortality. Perioperative risk assessment of patients with liver cirrhosis is a complex procedure. It consists of evaluation of general condition of the patient, including comorbidities and nutritional status, evaluation of the grade of liver disease, and urgency of the surgical procedure. There are no specific guidelines. Proper risk assessment before surgery, considering alternative ways of treatment, is a cornerstone of optimal postoperative course and prevention of complications in patients with liver cirrhosis.

Differentiation between systemic inflammatory response syndrome and sepsis in surgical patients is of crucial significance. Procalcitonin (PCT) and C-reactive protein (CRP) are widely used biomarkers, but PCT becomes compromised after antithymocyte globulin (ATG) administration, and CRP exhibits limited specificity. Presepsin has been suggested as an alternative biomarker of sepsis. This study aimed to demonstrate the role of presepsin in patients after heart transplantation (HTx). Plasma presepsin, PCT, and CRP were measured in 107 patients serially for up to 10 days following HTx. Time responses of biomarkers were evaluated for both noninfected (n=91) and infected (n=16) patients. Areas under the concentration curve differed in the two groups of patients for presepsin (P<.001), PCT (P<.005), and CRP (P<.001). The effect of time and infection was significant for all three biomarkers (P<.05 all). In contrast to PCT, presepsin was not influenced by ATG administration. More than 25% of noninfected patients had PCT above 42 μg/L on the first day, and the peak concentration of CRP in infected patients was reached on the third post-transplant day (median 135 mg/L). Presepsin seems to be as valuable a biomarker as PCT or CRP in the evaluation of infectious complications in patients after HTx., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Intestinal transplantation represents a suitable treatment for patients with intestinal failure who then develop life-threatening complications of total parenteral nutrition and for some patients with complex abdominal disorders not suitable for conventional treatment., Methods: prior to launch of the clinical program, preparation started in 2006 initially with extensive experimentation carried out on pigs. The clinical phase involved a specialized, multidisciplinary team who examined 23 patients being considered for transplantation. Seven patients were put on a waiting list and one female, due to the improvement of her medical status, was unlisted. The first ever intestinal transplantation was done in 2014., Results: three out of six transplanted patients are alive with 380 days of actual survival; median 131 days (63-763). Two patients are on a full oral diet and nutritionally independent with an excellent quality of life. One female is nutritionally independent but with the need for partial supplemental parenteral rehydration due to the stomal output., Conclusion: intestinal transplantation is a suitable treatment for highly selected patients with intestinal failure who meet specific listing criteria.

Living donor AB0 incompatible kidney transplantation represents a new tool how to improve the access to transplantation. Majority of European protocols are based on desensitization with rituximab, triple drug immunosuppression, intravenous immunoglobulins and specific immunoads option (IA) which eliminates isohaemaglutinins. AB0i kidney transplant program was initiated in our centre in 2011 and 21 patients have received grafts from incompatible donors until recently. Highest accepted isohaemaglutinins titers before rituximab were 1 : 64 and corresponding pretransplant immunoadsorption procedures varied from 2 to 9. In 5 patients 1-2 IA procedures were performed also after transplantation. With the advent of paired exchange program the AB0i transplantation is offered to patients with unsuccessful matching run or with aim to improve HLA match between donor and recipient. The main complications were postoperative bleeding and urinary tract infections in patients at risk. Majority of protocol biopsies exhibited positivity of C4d staining. Neither graft loss nor patient death were noticed.

Background: Sepsis belongs among the most serious conditions and animal models of sepsis are the basic tools to investigate the pathophysiological response to this condition., Material and Methods: A total of 16 adult minipigs with identical baseline parameters were randomized into two groups. In the sepsis group (n = 10), sepsis was induced using caecal ligation and puncture (CLP). The control group (n = 6) underwent laparotomy without CLP. Selected clinical and laboratory parameters as well as histological findings between the sepsis and control group were subsequently compared., Results: All animals undergoing CLP developed diffuse peritonitis and sepsis. Compared to the control group, experimental animals showed significant increase of body temperature and heart rate (while) requiring noradrenaline to maintain their perfusion pressure. No significant differences in the monitored biochemical parameters (including C-reactive protein levels) between the two groups were found. Histological findings in organs of experimental animals were consistent with changes of organs seen in sepsis, i.e., centrilobular liver necroses, acute tubular renal necrosis, serous fibrinopurulent exudate, myocardial malacias, and pulmonary edema., Conclusion: Experimental caecal ligation with a predefined size of the perforation in the intestinal wall is a suitable model for assessing the pathophysiological changes occurring in the body in sepsis.

Background: Between April 1995 and November 2005, 500 liver transplantations were performed in 476 patients of age from 3, till 70, at the Transplantation center of the Institute of Clinical and Experimental Medicine (IKEM) in Prague. The most common indications for liver transplantation were alcoholic liver cirrhosis (23%), hepatitis C cirrhosis (17%), and cholestatic cirrhosis (PBC and PSC, 9% each). Mean MELD score of recipients at the transplantation was 15-18 for each year of transplantation. Ten-years patient survival was 79.1 +/- 2.2%, and graft survival 74.1 +/- 2.1% respectively. Best patient and graft survival was achieved among patients transplanted for autoimmune liver diseases, the worst in group of patients with alcoholic cirrhosis. Malignancies were the most common cause of death during the period of follow-up (17 patients)., Methods and Results: Patients were followed longitudinally at the Department of hepatogastroenterology IKEM according to prospective protocol included protocol biopsies. Hypertension (in 71% of recipients), and overweight or obesity (in 56.3%), were the most prevalent medical complications among long-term survivors. Diabetes was found in 28.6%, of which 14.7% was de-nove diabetes after transplantation. Renal insufficiency (S-creatinin > 150 micromol/l) was present in 61 of 348 (17.6%) survivors. Out of these, 16 needed chronic hemodialysis, and 12 underwent kidney transplantation subsequently. Protocol biopsy at 5 years after transplantation was evaluated in a sample of 102 unselected liver transplant recipients. Normal liver was found in 4% of recipients, minor non-specific changes in 36% of them. Disease recurrence was present in all of 16 recipients transplanted for HCV cirrhosis, in one third of them graft cirrhosis was already present. Disease recurrence was found in patients transplanted for autoimmune disease frequently, PBC in 40%, PSC in 25%, and autoimmune hepatitis in 60% of recipients. Graft steatosis greater than 33% was present in 13% of recipients., Conclusions: Liver transplantation is highly effective method of treatment of end stage liver disease. Despite frequent medical complications, and disease recurrence on histological examination almost 80% of recipients transplanted in the liver transplantation program in IKEM survived more than 10 years after procedure. The survival achieved was far above that of the European liver transplant registry.

Acute liver failure is a life threatening illness whose mortality rate remains high. For the survival an early diagnosis is crucial as well as the use of specific and supportive therapy and the determination of patient's need for urgent liver transplantation. At the first signs of the disease progression it is necessary to contact a transplantation centre. The patient with acute liver failure should be admitted to intensive care unit of a hospital capable to perform liver transplantation. Liver transplantation is limited by the availability of organs. It is possible to expand the time required for spontaneous liver regeneration or transplantation by using liver supporting systems. The therapy of the acute liver failure is multidisciplinary and should be performed in specialized centers.

With increasing survival rates, liver transplantation has reached the mainstream of medical care. Due to the experience acquired with adult liver transplantation, the program of paediatric liver transplantation develops. The surgery technique and perioperative care have to reflect anatomic and physiologic differences in childhood. This report describes organisation and outcomes of the program of paediatric liver transplantation in Transplantcentre IKEM.

The Aim of the Study: Was to analyze in detail perioperative changes of renal function during orthotopic liver transplantation (OLT) and to identify risk factors, that were associated with the need of renal replacement therapy (RRT) during the first week after liver transplantation., Methods: Prospective study of 50 consecutive patients undergoing OLT was performed. Selected laboratory and clinical parameters were monitored prior to the procedure, after reperfusion, at the end of the procedure, and at 12 hours after the procedure. In the first post-transplant week, necessity to use RRT in the presence of acute kidney injury was monitored and the analysis of risk factors for the need for RRT was performed. Patient survival, graft function, need for dialysis and selected laboratory parameters were assessed at one year post-transplant., Results: During OLT, there was an increase in S(cr) and S(urea), which persisted as late as 12 hours post-transplant. There was a decrease in U(cr) and U(urea) and an increase in S(Na) and S(K). During the procedure any increase in S(cyst) were observed, increase the values were recorded 12 hours after surgery. S(bili) level decreased. There was a rise in the urinary levels of total protein, albumin and beta2-microglobulin. U(prot)/U(cr) increased significantly after reperfusion, with a peak after the procedure. At 12 hours after the procedure, there was a decrease in U(prot)/U(cr), but the values were still many times higher than those seen preoperatively. RRTwas necessary in 14% cases. Risk factors for acute kidney injury requiring RRT included a higher APACHE score, higher BMI, higher preoperative S(cr) and S(urea), hepatorenal syndrome pretransplant, blood loss and intraoperative hemodynamic instability, postoperative complications and dysfunction of the liver graft. One year after OLT, there was no difference in followed laboratory values between patients requiring postoperative RRT and others; no patient was treated with dialysis., Conclusion: OLT has a major impact on glomerular and tubular renal functions. Our data suggest that patients surviving acute renal injury treated with RRT in the early postoperative period have a high chance of restoring renal function. A sensitive marker of renal injury during OLT seems to be perioperative proteinuria.

Background: Development of biological and non-biological artificial liver devices in the previous 20 years enabled effective treatment of acute liver failure (ALF) of patients waiting for liver transplantation or for spontaneous liver parenchyma regeneration. Aim of the study was the evaluation of the effectiveness of biological (BAL - bioartificial liver) and non-biological (FPSA - Fractionated plasma separation and adsorption) methods in the treatment of experimental ALF on large laboratory animal., Methods and Results: Surgical model of ALF with liver devascularization in pigs (weight 25-40 kg) was provided following monitoring of ALF markers (AST, ALT, bilirubin, ammoniac, glycaemia, INR) including intracranial pressure (ICP). Control group included animals without treatment of ALF. Results of both experimental groups were compared and statistically worked-out with that of controls by T-test and Mann-Whitney non-parametric test by EXCEL and QUATRO. BAL group: 10 pigs (weight 30 +/- 5 kg) with ALF were treated by BAL with isolated hepatocytes. When plasma bilirubin was compared, significant differences (p < 0.05) in 6 and 9 hours interval were found favouring BAL group (18.1 vs. 13.1, 22.9 vs. 13.2 mmol/l). The value of ICP in both groups was no significant. Prometheus group: 14 pigs weight 35 kg (35 +/- 5 kg) with the identical ALF were treated by Prometheus (FPSA). Level of serum bilirubin in experimental group when compared to control group was significantly lower (p < 0.01) at 6 hour interval 12.81 +/- 6.54 vs. 29.84 +/- 9.99 at 9 hour 11.94 +/- 4.14 vs. 29.95 +/- 12.36 and at 12 hour 13.88 +/- 6.31 vs. 26.10 +/- 12.23 mmol/l. No significant difference in serum ammonia level was found. ICP was significantly different from 9 hour to 12 hour interval in favour of FPSA group (p < 0.01): 9 hour 19.1 +/- 4.09 vs. 24.1 +/- 2.85, 10 hour 21.9 +/- 3.63 vs. 25.1 +/- 2.19, 11 hour 22.5 +/- 3.98 vs. 26.3 +/- 3.50 and 12 hour 24.0 +/- 4.66 vs. 29.8 +/- 5.88 mm Hg., Conclusions: Significant improvement of bilirubin and ICP levels resulting from the treatment with fractionated plasma separation and adsorption (Prometheus) were observed in the case of experimental ALE Except the bilirubin levels, bioartificial liver provided by O. liver Performer with isolated hepatocytes did not bring any significant improvement of laboratory markers, including ICP.

Paper refers the first in Czech Republic liver transplantation in a child with the donor being the close living relative - the father. Indication was the chronic liver failure caused by biliary atresia after the Kasai procedures, which enabled the child to survive two years. Liver segments II. -III were transplanted with favourable postoperative development. Within the following twenty months the nutrition status and the psychomotor development of the child significantly improved. Authors discuss present situation and results of the paediatric liver transplantation in the world.

Aim: The aim of this study was to create an easily reproducible model of the acute hepatic failure (ASJ) in a minipig, which may allow to test supporting eliminating systems. The aim of this report was to describe the surgical technique with the anaesthesiological procedure and to demonstrate the experimental results on a group of the laboratory animals., Methodology: The ASJ was mocked using surgical devascularization of the liver: a ligature of the a. hepatica propria and v. portae, creating a portocaval anastomosis end-to-side. The animals were analgosedated during the experiment and were on a ventilatory support. Biochemical indicators of the hepatic failure, the ICP and the haemodynamics parameters were monitored. Hypoglycaemia with levels below 3.5 mmol and any increase of the intracranial pressure (ICP) were considered the onset of the hepatic failure., Material: 20 minipigs weighing 25-30 kg and divided in 3 groups, were included in the experiment: I--10 animals were assigned to the acute hepatic failure (ASJ) group, II--5 animals with the mock acute hepatic failure (ASJ), whose ICP was monitored in conjunction with the standard monitoring and III. 5 animals without the acute hepatic failure (ASJ)--a control group., Results: We proved significant differences in the AST levels (33.44 +/- 39.96 vs. 1.56 +/- 0.50 mmol/l), the lactate levels (2.97 +/- 1.16 vs. 1.18 +/- 0.61 mmol/l), and the ammonium levels (264.3 +/- 93.05 vs. 42.5 +/- 12.98 micromol/l) in the acute hepatic failure (ASJ) group compared with the control group (p < 0.01) 6 hours after the surgery and significant changes in the glycaemia levels and the intracranial pressure (ICP) measurements 4 hours after the surgical procedure. Increase in the pulse frequency, the blood pressure, decrease of the mean arterial pressure (MAP) and decrease in the systemic venous resistence index (SVRI) in the acute hepatic failure (ASJ) group was recorded 6 hours after the procedure compared with the initial findings, with significant differences between the acute hepatic failure (ASJ groups and the control group as late as during the 12th hour following the procedure (SVRI: 953 ASJ vs. 1658 control, p - 0.05, MAP: 58.1 ASJ vs. 76 control, p - 0.05). No statistically significant differences in the heart index between the acute hepatic failure (ASJ) group and the control group were recorded. The animals with the acute hepatic failure (ASJ) survived 13 hours following the surgical procedure, on average.

Background: The aim of our study was to compare the results of conventional tests and thromboelastography during liver transplantation and to determine their importance for blood loss., Methods and Results: Thromboelastography and conventional laboratory tests were undertaken in 25 patients at the end of the anhepatic phase. Transfusion requirements correlated significantly only with prothrombin time and reaction time, R. These two tests likewise correlated significantly one with the other., Conclusions: Lowered plasma levels of coagulation factors of the prothrombin complex influenced the blood losses in our patients. While not replacing conventional tests, thromboelastography can serve as an additional test for monitoring acute changes in hemostasis.