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Introduction . Streptococcus constellatus are opportunistic microorganisms. When immunocompromised patients with concomitant systemic diseases are infected with S.constellatus, the bacteria may cause sepsis. Case study. A patient was admitted to hospital due to septic shock and multi-organ dysfunction in the course of neck phlegmon. The microbiological system identified S. constellatus in the patient who worked as a dog groomer. These facts confirmed that this aetiological factor may have caused such a serious infection because S. constellatus is a bacterial species found in dogs. It is most likely that the bacteria colonised the patient. Zoonotic transmission of microorganisms is particularly important for the development of infections in dogs and humans. Knowledge about how to treat deep cervical infections is necessary in the daily practice of a maxillofacial surgeon. The right antibiotic can applied only when the strain causing the infection has been identified.

Dexmedetomidine is a hepatically eliminated drug with sedative, anxiolytic, sympatholytic, and analgesic properties that has been increasingly used for various indications in the form of a short or continuous intravenous infusion. This study aimed to propose a population pharmacokinetic (PK) model of dexmedetomidine in a heterogeneous group of intensive care unit patients, incorporating 29 covariates potentially linked with dexmedetomidine PK. Data were collected from 70 patients aged between 0.25 and 88 years and treated with dexmedetomidine infusion for various durations at 1 of 4 medical centers. Statistical analysis was performed using a nonlinear mixed-effect model. Categorical and continuous covariates including demographic data, hemodynamic parameters, biochemical markers, and 11 single-nucleotide polymorphisms were tested. A 2-compartment model was used to describe dexmedetomidine PK. An allometric/isometric scaling was used to account for body weight difference in PK parameters, and the Hill equation was used to describe the maturation of clearance. Typical values of the central and peripheral volume of distribution and the systemic and distribution clearance for a theoretical adult patient were central volume of distribution = 22.50 L, peripheral volume of distribution = 86.1 L, systemic clearance = 34.7 L/h, and distribution clearance = 40.8 L/h. The CYP1A2 genetic polymorphism and noradrenaline administration were identified as significant covariates for clearance. A population PK model of dexmedetomidine was successfully developed. The proposed model is well calibrated to the observed data. The identified covariates account for

Dexmedetomidine (DEX) is a fairly new alfa2-agonist which has been increasingly used in recent years for analgosedation, mostly because it offers a unique ability of providing both moderate level of sedation and analgesia without respiratory depression. Despite of many papers published, there are still only a few concerning the PK of the drug given as long-term infusion in ICU patients. The aim of this work was to characterize the population pharmacokinetics of dexmedetomidine and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in intensive care unit. This study was performed in the group of 17 males and 10 females patients with a median age of 59.5 years and median body weight of 75 kg. Blood samples for dexmedetomidine assay were collected from arterial catheter, during and after discontinuation of a standard infusion, that ranged from 24 to 102 h. The following covariates were examined to influence dexmedetomidine PK: age, sex, body weight, patients’ health status described by Sequential Organ Failure Assessment Score (SOFA), inotropes usage, and infusion duration. The dexmedetomidine PK was best described by a two-compartment model. The typical values of PK parameters were estimated as 27 L for the volume of the central compartment, 87.6 L for the volume of the peripheral compartment, 38.5 L/h (9.2 mL/min/kg for a 70 kg patient) for systemic clearance and 46.4 L/h for the distribution clearance. Those values are consistent with literature findings. We were unable to show any significant relationship between collected covariates and dexmedetomidine PK. This study does not provide sufficient evidence to support the individualization of dexmedetomidine dosing based on age, sex, body weight, SOFA, and infusion duration. Electronic supplementary material The online version of this article (10.1007/s10928-017-9564-7) contains supplementary material, which is available to authorized users.

Introduction Because of the high mortality of invasive fungal infections (IFIs), appropriate exposure to antifungals appears to be crucial for therapeutic efficacy and safety. Materials and methods This review summarises published pharmacokinetic data on systemically administered antifungals focusing on co-morbidities, target-site penetration, and combination antifungal therapy. Conclusions and discussion Amphotericin B is eliminated unchanged via urine and faeces. Flucytosine and fluconazole display low protein binding and are eliminated by the kidney. Itraconazole, voriconazole, posaconazole and isavuconazole are metabolised in the liver. Azoles are substrates and inhibitors of cytochrome P450 (CYP) isoenzymes and are therefore involved in numerous drug–drug interactions. Anidulafungin is spontaneously degraded in the plasma. Caspofungin and micafungin undergo enzymatic metabolism in the liver, which is independent of CYP. Although several drug–drug interactions occur during caspofungin and micafungin treatment, echinocandins display a lower potential for drug–drug interactions. Flucytosine and azoles penetrate into most of relevant tissues. Amphotericin B accumulates in the liver and in the spleen. Its concentrations in lung and kidney are intermediate and relatively low myocardium and brain. Tissue distribution of echinocandins is similar to that of amphotericin. Combination antifungal therapy is established for cryptococcosis but controversial in other IFIs such as invasive aspergillosis and mucormycosis.

The aim of this study was to characterize the pharmacokinetics (PK) of propofol in ICU patients undergoing long-term sedation and to assess the influence of routinely collected covariates on the PK parameters. Propofol concentration-time profiles were collected from 29 patients. Non-linear mixed-effects modelling in NONMEM 7.2 was used to analyse the observed data. The propofol pharmacokinetics was best described with a three-compartment disposition model. Non-parametric bootstrap and a visual predictive check were used to evaluate the adequacy of the developed model to describe the observations. The typical value of the propofol clearance (1.46 l/min) approximated the hepatic blood flow. The volume of distribution at steady state was high and was equal to 955.1 l, which is consistent with other studies involving propofol in ICU patients. There was no statistically significant covariate relationship between PK parameters and opioid type, SOFA score on the day of admission, APACHE II, predicted death rate, reason for ICU admission (sepsis, trauma or surgery), gender, body weight, age, infusion duration and C-reactive protein concentration. The population PK model was developed successfully to describe the time-course of propofol concentration in ICU patients undergoing prolonged sedation. Despite a very heterogeneous group of patients, consistent PK profiles were observed. Copyright © 2016 John Wiley & Sons, Ltd.

Patients with sepsis admitted to the intensive care unit often present with acid-base disorders. As the traditional interpretation might be clinically misleading, an alternative approach described by Stewart may allow one to quantify the individual components of acid-base abnormalities and provide an insight into their pathogenesis. The aim of our study was to compare the traditional and Stewart approaches in the analysis of acid-base disturbance.We analyzed arterial blood gases (ABG) taken from 43 ICU septic patients from admission to discharge categorising them according to SBE values. The traditional concept analysis was compared with the physicochemical approach using the Stewart equations.990 ABGs were analysed. In the SBE-2 mEq L⁻¹ group, hyperlactatemia was observed in 34.7% ABG, hypoalbuminemia in 100% and SIG acidosis in 42% ABG. Moreover, a Cl/Na ratio0.75 was present in 96.9% ABG. In the normal range SBE group, elevated lactates were present in 21.3% ABG, SIG acidosis in 14.9%, elevated Cl/Na ratio in 98.4% and hypoalbuminemia in all 324 ABG. In the metabolic alkalosis group (SBE+2 mEq L⁻¹), hyperlactatemia was observed in 18.4% ABG, SIG acidosis in 5% ABG, Cl/Na ratio0.75 in 88.8%, while 99.1% samples revealed hypoalbuminemia.The use of the Stewart model may improve our understanding of the underlying pathophysiological mechanism and the true etiology of the derangements of acid-base disorders. Indeed, it proves that patients may suffer from mixed arterial blood gas disorders hidden under normal values of SBE and pH.

Contains fulltext : 138898.pdf (Publisher’s version ) (Closed access) BACKGROUND: Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis. AIMS: We used data from the Extended Prevalence of Infection in Intensive Care (EPIC) II 1-day point-prevalence study to better define the characteristics of infection in these patients. METHODS: We compared characteristics, including occurrence and types of infections in non-cirrhotic and cirrhotic patients who had not undergone liver transplantation. RESULTS: The EPIC II database includes 13,796 adult patients from 1265 ICUs: 410 of the patients had cirrhosis. The prevalence of infection was higher in cirrhotic than in non-cirrhotic patients (59 vs. 51%, P < 0.01). The lungs were the most common site of infection in all patients, but abdominal infections were more common in cirrhotic than in non-cirrhotic patients (30 vs. 19%, P < 0.01). Infected cirrhotic patients more often had Gram-positive (56 vs. 47%, P < 0.05) isolates than did infected non-cirrhotic patients. Methicillin-resistant Staphylococcus aureus (MRSA) was more frequent in cirrhotic patients. The hospital mortality rate of cirrhotic patients was 42%, compared to 24% in the non-cirrhotic population (P < 0.001). Severe sepsis and septic shock were associated with higher in-hospital mortality rates in cirrhotic than in non-cirrhotic patients (41% and 71% vs. 30% and 49%, respectively, P < 0.05). CONCLUSIONS: Infection is more common in cirrhotic than in non-cirrhotic ICU patients and more commonly caused by Gram-positive organisms, including MRSA. Infection in patients with cirrhosis was associated with higher mortality rates than in non-cirrhotic patients.

This case report presents a 49 year-old female with type 1 diabetes admitted to the intensive care unit with acute respiratory failure and severe diabetic ketoacidosis with an initial measurement of blood glucose level of 1,200 mg L⁻¹, pH 6.78, serum HCO₃ ⁻ 3.2 mmoL L⁻¹ and BE -31.2 mmoL L⁻¹. Analysis of the blood gasometric parameters with the Stewart approach and the traditional Henderson-Hasselbalch concept enabled the discovery of metabolic acidosis caused by unidentified anions (mainly ketons). A treatment protocol with intensive fluid management with 0.9% NaCl, intensive intravenous insulin therapy, and potassium supplementation was administered. Analysis of the gasometric parameters after 12 hours of treatment according to the Stewart approach compared to the Henderson-Hasselbalch concept disclosed that metabolic acidosis caused by the unidentified anions has resolved almost completely and been replaced by metabolic hyperchloremic acidosis. The hyperchloremic acidosis was caused by the intensive fluid resuscitation with 0.9% NaCl, which contains a high chloride load, exceeding the chloride levels observed in human serum. Fluid management with balanced fluids other than saline was continued, together with intravenous insulin infusion, potassium supplementation, and 5% glucose administration. Analysis of this case study revealed the advantages of the Stewart approach to acid base abnormalities compared to the traditional Henderson-Hasselbalch concept. The Stewart approach allows the diagnosis of the exact causes of severe life-threatening metabolic acidosis and the appropriate modification of the therapeutic mangement of patients with diabetic ketoacidosis.

Interpreting acid base disturbances according to the physicochemical Stewart approach allows the cause of such abnormalities to be discovered. This method is based on three independent variables: SID (strong ion difference), mainly sodium and chloride; weak acids concentration - Atot, mainly albumins and phosphate; and carbon dioxide tension - pCO₂. These three independent variables are responsible for the change of water dissociation and for the change in H+ concentration and, consequently, the change in serum pH value. The SID value of the fluids administered to a patient is responsible for the change of serum SID value and therefore causes a change in the patient's acid base status. During the infusion of a given fluid, the SID value of the serum becomes closer to the SID value of that fluid; on the other hand, the infusion causes a decrease in Atot concentration. In order to avoid acid base disturbances connected with fluid administration, the SID value of fluids being administered should be greater than 0 and lower then the serum SID. It has been suggested that fluids should be given of which the SID value is as close as possible to the actual serum HCO₃ concentration. Knowing the SID value of the fluid administered, and the serum HCO₃ concentration, one can expect a change of serum pH after a fluid infusion. Administering a fluid with a SID greater than the HCO₃ concentration causes a pH increase towards alkalosis. Likewise, administering a a fluid with a SID lower than the HCO₃ concentration causes a pH decrease towards acidosis. It seems that knowledge of the electrolyte concentration and the SID value of an administered fluid is an important factor regarding acid base disturbances.

Antibiotics are the most commonly used drugs in intensive care unit patients and their supply should be based on pharmacokinetic/pharmacodynamic rules. The changes that occur in septic patients who are critically ill may be responsible for subtherapeutic antibiotic concentrations leading to poorer clinical outcomes. Evolving in time the disturbed pathophysiology in severe sepsis (high cardiac output, glomerular hyperfiltration) and therapeutic interventions (e.g. haemodynamically active drugs, mechanical ventilation, renal replacement therapy) alters antibiotic pharmacokinetics mainly through an increase in the volume of distribution and altered drug clearance. The lack of new and efficacious drugs and increased bacterial resistance are current problems of contemporary antibiotic therapy. Although intermittent administration is a standard clinical practice, alternative methods of antibiotic administration are sought, which may potentialise effects and reduce toxicity as well as contribute to inhibition of bacterial resistance. A wide range of studies prove that the application of continuous infusion of time-dependent antibiotics (beta-lactams, glycopeptides) is more rational than standard intermittent administration. However, there are also studies which do not confirm the advantage of one method over the other. In spite of controversy the continuous administration of this group of antibiotics is common practice, because the results of both studies point to the higher efficacy of this method in critically ill patients. Authors reviewed the literature to determine whether any clinical benefits exist for administration of time-dependent antibiotics by continuous infusion. Definite specification of the clinical advantage of administration this way over standard dosage requires a large-scale multi-centre randomised controlled trial.

The aim of this study was to characterize the pharmacokinetics (PK) of propofol in ICU patients undergoing long-term sedation and to assess the influence of routinely collected covariates on the PK parameters. Propofol concentration-time profiles were collected from 29 patients. Non-linear mixed-effects modelling in NONMEM 7.2 was used to analyse the observed data. The propofol pharmacokinetics was best described with a three-compartment disposition model. Non-parametric bootstrap and a visual predictive check were used to evaluate the adequacy of the developed model to describe the observations. The typical value of the propofol clearance (1.46 l/min) approximated the hepatic blood flow. The volume of distribution at steady state was high and was equal to 955.1 l, which is consistent with other studies involving propofol in ICU patients. There was no statistically significant covariate relationship between PK parameters and opioid type, SOFA score on the day of admission, APACHE II, predicted death rate, reason for ICU admission (sepsis, trauma or surgery), gender, body weight, age, infusion duration and C-reactive protein concentration. The population PK model was developed successfully to describe the time-course of propofol concentration in ICU patients undergoing prolonged sedation. Despite a very heterogeneous group of patients, consistent PK profiles were observed. Copyright © 2016 John WileySons, Ltd.

During the adhesive locomotion of land snails a series of short dark transverse bands, called pedal or foot waves, is visible ifa moving snail's ventral surface is observed through a sheet of glass. Moreover, the mucus secreted from the pedal glands and some pedal epithelial cells forms a thin layer which acts as a glue augmenting adherence, while also acting as a lubricant under the moving parts of the snail's foot. The relationships between velocity and the frequency of pedal waves as well as changes in the volume of small air bubbles under foot waves were analyzed by means of digital recordings made through a glass sheet on which the snails were moving. On the ventral surface of a moving snail foot, the adhering parts of the foot constituted about 80% of the total area, while several moving parts only about 20%. The single moving region of the foot (the pedal wave) amounted to about 3% of snail length. The epithelium in the region of the pedal wave was arched above the substrate and was also more wrinkled than the stationary epithelium, which enabled the forward motion of each specific point of epithelium during the passage of a pedal wave above it. The actual area of epithelium engaged by a pedal wave was at least 30% greater than the area of the epithelium as recorded through a glass sheet. In the region of the pedal wave, the tiny subepithelial muscles acting on the epithelium move it up in the front part of the wave, and then down at the end of the wave, operating vertically in relation to the substrate. In the middle part of the wave, the epithelium only moves forward. In summary, during the adhesive locomotion of snails, the horizontal movement of the ventral surface epithelium proceeds as temporally separate phases of upward, forward and downward movement.

Summary Background Splenic artery aneurysm is the most common aneurysm of visceral vessels. Their rupture usually leads to massive bleeding, being a direct life threat. Splenic artery aneurysms usually rupture into the free peritoneal cavity, and much less frequently into the lumen of the gastrointestinal tract. Case Report We describe the case of a 38-year-old male patient, who, as a result of chronic pancreatitis, developed a false aneurysm of the splenic artery, which initially caused necrosis of the large intestine and bleeding into its lumen, and subsequently necrosis of the posterior stomach wall with the aneurysm rupture to the stomach lumen with a dramatic course. Conclusions The case described confirms that splenic artery aneurysm can be a cause of bleeding to both upper and lower parts of the gastrointestinal tract, and the aneurysm rupture is usually of a dramatic and life-threatening course.

The transepithelial potential difference and changes of diameter of isolated snail intestine as index of its motility were studied in immersed bath in control conditions and after gentle stimulation by 60 seconds of washing of the intestinal lumen. Immediate depolarization and 20% augmentation of the lumen were observed during the stimulation. After stimulation, additional transient depolarization of the transepithelial potential difference and gradual diminution of intestine lumen back to control values over a period of 20 minutes occurred. The immediate reaction was greatly influenced by the presence of sodium or chloride ion transport inhibitors, however, the late phase of the response was not. It is hypothesized that changes of transepithelial electrogenic ion transport and of intestinal motility during the stimulation mirror the inflow of intestinal content and after completion of stimulation may be related to its storage.

INTRODUCTION Hyperglycemia in sepsis is managed by intensive insulin therapy, which can cause hypoglycemia. OBJECTIVES The aim of the study was to evaluate the glycemic profile as well as safety and effectiveness of a nurse-controlled insulin therapy protocol in patients with severe sepsis and septic shock. PATIENTS AND METHODS The study included 16 septic patients who died (nonsurvivors) and 61 septic patients who survived. Glycemia was measured every 4 h, and the dose of insulin infusion was adjusted to maintain glycemia of 4.4 mmol/l to 8.3 mmol/l. We analyzed glycemia levels and daily variations, insulin dose, episodes of hypo- and hyperglycemia. RESULTS Nonsurvivors and survivors had similar mean glycemia levels (7.38 vs. 7.08 mmol/l; p = 0.20) and insulin requirements (median [Me] = 26.9 vs. 23.9 units/d; p = 0.22; Me = 1.7 vs. 1.4 units/h; p = 0.25). Daily glycemia variation (Me = 4.81 vs. 3.03 mmol/l; p

Summary Background The authors would like to present the problem of performing bedside tracheotomy in the Intensive Care Unit. The tracheotomy have been done in the highly specific group in poor or fatal general condition, so the complication rate according to the general status of the patients is discussed. Material 92 patients were treated with tracheotomy between I 2003 – XII 2005 and in this number 13 complications occurred. The general status of the patients (shock, stroke, sepsis, pneumonia, hypoalbuminemy) in the time of procedure was taken into consideration. Results In early complications dominated the bleeding – in 7 patients (7,9%) and wound infections – in 4 patients. Tracheal strictures, the only late complication found in our group, were stated during the follow up period in 2 patients (1,1%). The time of performing the tracheotomy i.e. day of the intubation (range from 0–13; mean – 5,7) and day of the decaniulation (range from 3–65; mean – 16) were analyzed. Conclusion Tracheotomy performed in the Intensive Care Unit as a bedside procedure is safe, quick and effective. Complication rate in the group of patients in poor general condition is comparable both to the average population and to the percutaneous technique.

Introduction: As a pathogen, Budvicia aquatica is a rarely cultured micro‐organism. It was first isolated in the Czech Republic in 1983. It can chiefly be found in the waters of streams, rivers, wells and swimming pools, but it may cause infections in immunocompromised patients. Case presentation: On 4 October 2013, a 67‐year‐old male patient was admitted to the Intensive Care Unit from the Neurological Department due to a deterioration of his general state and the occurrence of acute respiratory failure in the course of Guillain–Barre Syndrome. A urine culture was routinely prepared when his urinary catheter was exchanged on 2 November 2013, and more than 105 c.f.u. B. aquatica ml–1 was cultured, although no symptoms of infection were diagnosed. The patient did not require antibiotic therapy. Conclusion: It is possible that the absence of symptoms of infection resulted from the immunomodulatory effect of IgG, which the patient had received to treat the underlying disease, and to the regular exchange of his urinary catheter.

Background African trypanosomiasis is a parasitic infection sporadically imported to Europe by tourists or immigrants returning from endemic areas. We present the first and an unusual case of East African trypanosomiasis imported to Poland by a patient returning from a tourist trip to Uganda and Rwanda, which was successfully treated with pentamidine. Case presentation A 61-year-old Polish man was admitted to the Department because of high-grade fever and multi-organ dysfunction after a tourist trip to East Africa. He experienced a single tsetse fly bite during a safari trip to the Queen Elizabeth National Park in Uganda. On admission, his clinical status was severe, with high fever of 41ºC, preceded by chills, bleeding from the gums and oral mucosa, haemorrhages at the sites of venipuncture, numerous ecchymoses, fine-spotted skin rash, tachycardia, hepatosplenomegaly, dehydration, jaundice, dyspnoea, hypoxaemia, generalised oedema and oliguria. There was a typical non-painful trypanosomal chancre with central necrosis and peripheral erythema on his left arm. Laboratory investigations showed leucopenia, thrombocytopenia, haemolytic anaemia, hyperbilirubinaemia, hypoglycaemia, elevated creatinine and urea, high activity of aminotransferases, elevated levels of inflammatory markers, hypoproteinaemia, proteinuria, abnormal clotting and bleeding times, low fibrinogen level, metabolic acidosis, and electrolyte disturbances. A peripheral blood smear showed numerous Trypanosoma brucei trypomastigotes with a massive parasitaemia of 100,000/μl. T. brucei rhodesiense subspecies was finally identified on the basis of the characteristic serum resistance-associated gene using a polymerase chain reaction, and a seroconversion of specific immunoglobulin M and G antibodies in the peripheral blood by enzyme-linked immunosorbent assay. Serological tests for T. brucei gambiense subspecies were negative. A severe clinical course of acute rhodesiense trypanosomiasis with renal failure, respiratory distress, disseminated intravascular coagulation syndrome, haemolysis, liver insufficiency and myocarditis was confirmed. Intensive anti-parasitic and symptomatic treatment was immediately instituted, including intravenous pentamidine, plasmaphereses, oxygen therapy, blood transfusion, catecholamine administration, and fluid infusions, as well as haemostatic, hepatoprotective, anti-inflammatory, antipyretic and diuretic drugs. The final outcome was a full recovery with no late sequelae. Conclusion Sleeping sickness should always be considered in the differential diagnosis of fever in people returning from safari trips to the national parks or nature reserves of sub-Saharan Africa.

This case report presents a 49 year-old female with type 1 diabetes admitted to the intensive care unit with acute respiratory failure and severe diabetic ketoacidosis with an initial measurement of blood glucose level of 1,200 mg L⁻¹, pH 6.78, serum HCO₃ ⁻ 3.2 mmoL L⁻¹ and BE -31.2 mmoL L⁻¹. Analysis of the blood gasometric parameters with the Stewart approach and the traditional Henderson-Hasselbalch concept enabled the discovery of metabolic acidosis caused by unidentified anions (mainly ketons). A treatment protocol with intensive fluid management with 0.9% NaCl, intensive intravenous insulin therapy, and potassium supplementation was administered. Analysis of the gasometric parameters after 12 hours of treatment according to the Stewart approach compared to the Henderson-Hasselbalch concept disclosed that metabolic acidosis caused by the unidentified anions has resolved almost completely and been replaced by metabolic hyperchloremic acidosis. The hyperchloremic acidosis was caused by the intensive fluid resuscitation with 0.9% NaCl, which contains a high chloride load, exceeding the chloride levels observed in human serum. Fluid management with balanced fluids other than saline was continued, together with intravenous insulin infusion, potassium supplementation, and 5% glucose administration. Analysis of this case study revealed the advantages of the Stewart approach to acid base abnormalities compared to the traditional Henderson-Hasselbalch concept. The Stewart approach allows the diagnosis of the exact causes of severe life-threatening metabolic acidosis and the appropriate modification of the therapeutic mangement of patients with diabetic ketoacidosis.

Background: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II.Methods: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days.Results: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 ± 16 years, SAPS II score 39 ± 16, SOFA score 7.6 ± 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for ≤2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality.Conclusions: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections. © 2014 De Waele et al. licensee BioMed Central Ltd., SCOPUS: ar.j, info:eu-repo/semantics/published

To investigate the pharmacokinetics and pharmacodynamics of ciprofloxacin in critically ill patients after the first intravenous administration of 400 mg.Plasma concentrations were measured in 20 critically ill patients (mean [SD]; age, 55.5 [16.5] years; weight, 80.3 [16.9] kg; and creatinine clearance, 110.0 [71.5] mL/min). Four blood samples were drawn at the following time points 0, 0.5, 6 , 8 hours after infusion. Ciprofloxacin concentrations were determined by high-performance liquid chromatography.In the cases where ciprofloxacin was applied in targeted antibiotic therapy the minimum inhibitory concentrations (MIC) were ≤0.5 mg/l. The maximum and minimum plasma concentrations of ciprofloxacin were 1.74 (0.58-7.90) and 0.45 (0.16-2.96) mg/l, respectively. The main pharmacokinetic parameters for ciprofloxacin in the analyzed patients were as follows: k(el), 0.21 h-1; t(1/2kel), 3.37 h; AUC(0-inf), 10.10 mg×h/l; AUMC(0-last), 15.36 mg×h(2)/l; MRT, 1.71 h; V(d), 214.8 l; Cl, 39.70 l/h. Considering the maximum value of MIC (0.5 mg/l) only 30% and 25% of analyzed patients had desired values of the PK/PD indexes AUIC125 and C(max) /MIC10, respectively.The target plasma concentrations after the first dose of ciprofloxacin were reached only in a few critically ill patients. Considerable inter-subject variability for PK/PD parameters in ICU patients requires systematic monitoring.

Objectives: To provide a global, up-to-date picture of the prevalence, treatment, and outcomes of Candida bloodstream infections in intensive care unit patients and compare Candida with bacterial bloodstream infection. Design: A retrospective analysis of the Extended Prevalence of Infection in the ICU Study (EPIC II). Demographic, physiological, infection-related and therapeutic data were collected. Patients were grouped as having Candida, Gram-positive, Gram-negative, and combined Candida/bacterial bloodstream infection. Outcome data were assessed at intensive care unit and hospital discharge. Setting: EPIC II included 1265 intensive care units in 76 countries. Patients: Patients in participating intensive care units on study day. Interventions: None. MEASUREMENT AND MAIN RESULTS:: Of the 14,414 patients in EPIC II, 99 patients had Candida bloodstream infections for a prevalence of 6.9 per 1000 patients. Sixty-one patients had candidemia alone and 38 patients had combined bloodstream infections. Candida albicans (n = 70) was the predominant species. Primary therapy included monotherapy with fluconazole (n = 39), caspofungin (n = 16), and a polyene-based product (n = 12). Combination therapy was infrequently used (n = 10). Compared with patients with Gram-positive (n = 420) and Gram-negative (n = 264) bloodstream infections, patients with candidemia were more likely to have solid tumors (p < .05) and appeared to have been in an intensive care unit longer (14 days [range, 5-25 days], 8 days [range, 3-20 days], and 10 days [range, 2-23 days], respectively), but this difference was not statistically significant. Severity of illness and organ dysfunction scores were similar between groups. Patients with Candida bloodstream infections, compared with patients with Gram-positive and Gram-negative bloodstream infections, had the greatest crude intensive care unit mortality rates (42.6%, 25.3%, and 29.1%, respectively) and longer intensive care unit lengths of stay (median [interquartile range]) (33 days [18-44], 20 days [9-43], and 21 days [8-46], respectively); however, these differences were not statistically significant. Conclusion: Candidemia remains a significant problem in intensive care units patients. In the EPIC II population, Candida albicans was the most common organism and fluconazole remained the predominant antifungal agent used. Candida bloodstream infections are associated with high intensive care unit and hospital mortality rates and resource use. Copyright 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

The guidelines for management of sepsis are constantly updated, nevertheless sepsis is still a difficult clinical problem, especially as its treatment often ends in failure. Hospitalized cancer patients diagnosed with sepsis are especially concerned, as sepsis death rate is significant in that group of patients. The aim of the study was to evaluate and compare cancer- and non-cancer patients diagnosed with sepsis.The medical records of 56 patients diagnosed with sepsis from January 1. 2007 to August 1. 2008 were reviewed retrospectively. Patients were divided into two groups: 1 group--patients with sepsis and cancer (S+N), II group--patients with sepsis without cancer (S). The etiology of sepsis, primary infectious sources, chosen clinical and laboratory parameters and mortality were analysed.56 patients were involved in the study. The mean age for S+N patients was higher than for group S (61.3 vs. 45.5 years; p = 0.005). The mean APACHE II score value at the day of admission for the whole population was 22.1 +/- 8.8 (8-45), for S+N group--25.3 +/- 10.3 (12-41) and for group S--21.2 +/- 8.3 (8-45) (p = 0.308). The estimated risk of hospital death was retrospectively 43.4%, 53.3% and 39.0%. Patients in group S+N required larger infusion of minimal noradrenaline doses than the other patients (p = 0.015). The mortality rate was 14.3% and was higher in group S+N than in group S (16.7 vs. 13.6%). Mortality was also significantly higher among patients with larger lactate blood concentration (death: 4.6 vs. survival: 1.9 mmol/l; p = 0.020) and greater base deficit (death: -6.79 vs. survival: -2.34 mmol/l; p = 0,0006). Patients of lower mean arterial pressure (60.8 vs. 75.9 mmHg; p = 0.007) and who required larger noradrenaline infusion (0.514 vs. 0.232 microg/kg/min; p = 0.0009) at the day of admission had a significantly higher risk of death.The analysis did not indicate evidently higher risk of more severe sepsis's course in cancer sepsis patients. However the severity of patients' general condition estimated by the APACHE II score and the mortality in this group of patients was higher (statistically insignificant results). Patients in group S+N required larger minimal doses of noradrenaline and larger infusion of colloid at the day of admission. The mortality was determined by the haemodynamic disturbance and the severity of general condition, rather than the cancer diagnosis per se.

OBJECTIVES Toluene diisocyanate (TDI) due to its widespread use in industry is one of the most common and well-known causes of occupational asthma and Reactive Airways Dysfunction Syndrome (RADS). In this study the impact of TDI on the electrophysiological properties of the airways wall, particularly on the mechanisms of absorption of sodium ions and chloride ions secretion was evaluated. MATERIALS AND METHODS Isolated rabbit tracheal wall (from outbred stock animals) was mounted in an apparatus for electrophysiological experiments by means of Ussing method and was mechanically stimulated by the jet flux of specified fluid directed onto the mucosal surface of the tissue from a peristaltic pump. The measured parameters were: transepithelial potential difference under control conditions (PD, mV), after mechanical stimulation (dPD or physiological reaction of hyperpolarization, mV) and electric resistance (R, Omega cm2). When TDI (0.035 mM) was added to stimulation fluid, only the immediate reaction was identified and when it was added to incubation fluid and other experimental fluids, the late (post-incubation) reaction was determined. The experiments involving the inhibition of Na+ by amiloride and Cl- by bumetanide were also performed. RESULTS A series of functional tests for 72 pieces of tracheal wall from 36 animals were performed. It has been shown that short-term exposure to TDI significantly changed the course of reactions to mechanical stimulation. Also after incubation in the presence of TDI, the reactions to mechanical stimulation were changed in relation to control conditions. CONCLUSIONS The immediate reaction of the isolated rabbit tracheal wall after exposure to TDI depends on the duration of exposure and on the physiological condition of the tissue in respect of sodium and chloride ion transport.

Usefulness and economic aspects of microbiological analysis of central venous catheter (CVC) tips in diagnosis of the catheter-related bloodstream infection (CRBSI).Retrospective study of an adult intensive care unit in a university hospital. Catheter removal was performed when the clinical state of the patient indicated that the catheter could be the source of infection or inflammation was observed at the puncture site.We microbiologically studied 238 CVC tips according to the Maki method and 723 blood samples from 120 septic patients treated during a 21-month period (32.9% of all patients treated in this time period). In 115 cases (48.4%), the tips were positive. Bacteremia was ascertained in 181 blood samples (24.1%), and 168 samples were collected at the time of CVC removal. In blood samples taken from 20 patients (3% of total blood samples), 25 cases of the same pathogens were isolated from CVC tips. In 12 cases, pathogens found in blood and CVC tips were also cultured in other places. In 13 cases (5.5% of tips), CVCs were the source of CRBSI. Positive predictive value (PPV) and negative predictive value reached 11% and 91%, respectively. The total cost of CVC tip monitoring was about 4000 euro.Our data support the hypothesis that colonization of CVC is rarely responsible for CRBSI. Relatively low PPV renders tips culture useless as a method of diagnosing CRBSI. Based on these results, the routine microbiological monitoring of CVC tips was discontinued to reduce the cost of treatment.

Background : Despite recent advancements, Functional Mitral Regurgitation (FMR), secondary to dilated cardiomyopathy remains a common clinical problem. Conventional cardiac surgery therapies have high procedural risk and therefore new techniques for percutaneous repair of mitral valve are being developed. Aim. The purpose of the study was to verify the acute efficacy of percutaneous mitral valve repair in patients with FMR by transesophageal echocardiography (TEE) Methods : We analyzed consecutive cases of percutaneous mitral valve repair with CARILLON ™ Mitral Contour System ™ (Cardiac Dimensions® Inc.) performed in a single center. The technique is based on implantation into the coronary venous system, where the device applies tension to the mitral ring in order to improve coaptation of the leaflets. TEE was performed during the procedure in the cath lab. Measurements before and immediately after the device release at the end of the procedure are given. Results The procedure was attempted in 17 cases of secondary MR with no apparent organic changes on the leaflets. Successful implantation of the device was performed in 13 patients (12M and 1F, aged 48 – 67 yrs). The TEE parameters of the MR significantly changed after the procedure as compared to before the procedure, including vena contracta (0.43±0.13 vs 0.68±0.16cm, p=0.024), EROA (0.21±0.06 vs 0.27±0.08cm 2 , p=0.019) and MR jet area/LA area (37.31 ±11,51 vs 53.82±14,14%, p=0.001). In 4 patients the device was recaptured due to compromised circumflex artery (3pts) and/or lack of measurable improvement in TEE (2 pts). No procedural complications were observed. Conclusion The implantation of CARILLON ™ system is feasible and safe in patients with Functional MR. Initial observations on efficacy justify completion of large clinical trials aiming at establishing the role of the technique in clinical practice.

The authors would like to present the problem of performing bedside tracheotomy in the Intensive Care Unit. The tracheotomy have been done in the highly specific group in poor or fatal general condition, so the complication rate according to the general status of the patients is discussed.92 patients were treated with tracheotomy between I 2003-XII 2005 and in this number 13 complications occurred. The general status of the patients (shock, stroke, sepsis, pneumonia, hypoalbuminemy) in the time of procedure was taken into consideration.In early complications dominated the bleeding--in 7 patients (7.9%) and wound infections--in 4 patients. Tracheal strictures, the only late complication found in our group, were stated during the follow up period in 2 patients (1.1%). The time of performing the tracheotomy i.e. day of the intubation (range from 0-13; mean--5.7) and day of the decaniulation (range from 3-65; mean--16) were analyzed.Tracheotomy performed in the Intensive Care Unit as a bedside procedure is safe, quick and effective. Complication rate in the group of patients in poor general condition is comparable both to the average population and to the percutaneous technique.

Mitral regurgitation may result from left ventricular dilatation and cause progression of heart failure. Percutaneous techniques for mitral valve repair are under development. Techniques utilizing a trans-coronary venous approach exploit the anatomical relationship between the mitral annulus and the venous system of the heart. The coronary sinus, great cardiac vein and the origin of the anterior interventricular vein surround the posterior mitral annulus. This enables percutaneous approaches to annuloplasty for mitral regurgitation. Devices can be implanted into the coronary veins that modify the shape and size of the mitral annulus. We present a case of ischaemic mitral regurgitation successfully treated by use of a percutaneous approach, the Carillon Mitral Contour System. Significant reduction of the mitral regurgitation jet was observed. The patient was discharged 4 days after the procedure. During the follow-up visits, the patient showed an improved general condition and increased exercise capacity. Procedural steps are shown in detail and the current status of the coronary sinus based technique is discussed. Percutaneous techniques for mitral valve repair may be an attractive alternative to cardiac surgery in heart failure patients with secondary mitral regurgitation. The Carillon Mitral Contour System is under ongoing clinical evaluation in the AMADEUS trial.

Tracheotomy as an operation may be connected with many complications. One of them is intra- or postoperative bleeding. A lot of reasons of such bleeding is well known, but we describe a case of bleeding caused by central venous catheter which was inserted into external jugular vein, but dislocated into anterior jugular vein and destructed it's wall. The bleeding observed after tracheotomy was firstly counted as an effect of coagulation defect connected with heparin supply. When few days after tracheotomy the tip of the catheter was seen in the tracheotomy, patient was quickly operated--the destructed anterior jugular vein and external jugular vein were ligated and the central venous catheter was removed.

Bidirectional transport of Na+ and Cl- ions by the epithelium controls production and composition of airway surface liquid and airway transepithelial potential difference and in these ways supports mucociliary transport. Volatile anesthetics are able to inhibit epithelial ion transport processes when applied at high concentration and have been suggested to elicit depression of airway clearance and both these effects could be involved in postoperative pulmonary complications. The goal of these studies was to reveal possible influence of halothane and isoflurane at lower concentrations on electrogenic ion transport in airway epithelium. These studies were performed on the isolated rabbit tracheal wall mounted in the Ussing chamber. The reaction of the preparation to the gentle mechanical stimulation performed as a jet flux was examined without or in the presence of anesthetics at concentration equivalent to 0.5 minimal anesthetic concentration of volatile anesthetics in pulmonary alveoli (MAC), 1 MAC, 2 MAC, 5 MAC and 10 MAC. The volatile anesthetics at concentrations equivalent to 5 and 10 MAC affected airway transepithelial potential difference and influenced hyperpolarization or depolarization reactions which occurred after mechanical stimulation. The above effects were present when Na+ transport was inhibited by amiloride. The disturbed epithelial Cl- transport may be proposed as an explanation of the action of volatile anesthetics on electrophysiological parameters of the isolated tracheal wall although the influence of anesthetics on tachykinin secretion from C-fiber endings, which are present in the preparation, should also be taken into consideration. The long-lasting action (tens of minutes) of volatile anesthetics on the isolated tracheal wall should be also studied in the future as a model of airway reaction to prolonged volatile anesthesia.

The case of 19-year old men with iatrogenic esophageal wall perforation is presented. The patient underwent anterior cervical stabilization using plate and screw for fracture of the C4 and C5 vertebra followed by an abscess of prevertebral space with discharging pus and food from the wound. The general condition was poor. Symptoms included: pneumonia, pleuritis with effusion, septicemia with mediastinitis, fever up to 40 and quadriplegia on neurological examination. During surgical procedure the implant loose but was still fixed into the esophagus causing a large defect in the posterior wall of the hypopharynx and cervical part of esophagus was found. The patient undergone three step surgery with wide drainage of prevertebral abscess, removing of osteosynthetic plate removal and formation of pedicle flap with sterno-cleido-mastoideus muscule. The finnal fourth procedure with using of pediculed infrahyoid flap gave an excellent result. During 160 days hospitalization the pus culture showed growth of the 11 bacterials species (like Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus faecalis) and 2 species of fungus. He was treated 13 types of antybiotics. This special case we present because of live threatening complication (mediastinitis) and complicated clinical course as well as because of unique technique of the defect closure, i.e. the infrahyoid flap occurred to be successful.

Volatile anesthetics are suggested to elicit depression of airway clearance. The involvement of changes in transepithelial ion transport in this inhibition has already been observed. The Ussing method was used to study the changes in mechanical stimulation evoked electrogenic ion transport in isolated rabbit tracheal wall in the presence of halothane and isoflurane. The drugs dissolved in Ringer solution were directed as a flux from peristaltic pump to mucosal surface of trachea. In experimental settings without or with amiloride, the anestethics elicited reversible inhibition of stimulated ion transport and depolarization of transepithelial potential difference. Participation of chloride ion transport in observed changes is suggested. In the light of this study with application of anesthetics at higher concentrations than clinically relevant, the possibility of disturbances of airway transepithelial ion transport by clinically relevant concentration should be checked.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue bacterial infection. We present a serious case of a 43-year-old male who suffered from necrotizing fasciitis of the left leg in whom a delayed diagnosis caused multiorgan dysfunction. Early recognition of important symptoms is essential in the management and surgical debridement of necrotizing fasciitis. Treatment should include comprehensive supportive measures (early goal-directed therapy, adequate ventilation strategy, activated protein C dosage, tight glucose control, steroids, renal replacement therapy) and early antibiotic therapy based on microbiologic monitoring. The pathophysiology and etiologic factors of necrotizing fasciitis are discussed.