INTRODUCTION: Dynamic indices of fluid responsiveness (FR) such as pulse pressure variation (PPV) and stroke volume variation (SVV) differ among hemodynamic monitors, which use proprietary algorithms, and vary even over a short period of time. We aimed to compare the baseline values, fluctuation and predictive value for FR of PPV and SVV measured by three minimally invasive monitors. PATIENTS AND METHODS: Twenty patients undergoing high-risk abdominal surgery were included and 45 fluid challenges were analysed. The patients were simultaneously monitored using Carescape B650, LiDCO Rapid and FloTrac/Vigileo system. Cardiac output (CO), PPV and SVV were recorded before and after the fluid challenge of 500 ml of balanced crystalloid solution. An increase in CO ≥ 15 % defined fluid responders. Concurrently recorded arterial waveform was used for offline calculation of PPV. RESULTS: Mean baseline values of the indices ranged between 8.6 % and 13.4 %. LiDCO showed higher fluctuation of indices compared to the other monitors. Area under the receiver operating characteristic curve (AUROC) ranged from 0.71 to 0.76 with optimal cut-off value between 7.5 % and 13.9 %. AUROC increased for all indices when FR was defined as an increase in stroke volume. Furthermore, a decrease in PPV or SVV after fluid challenge (ΔPPV, ΔSVV) proved a better marker of FR (AUROC 0.82-0.93) than baseline values with a uniform threshold of approximately -3%. CONCLUSIONS: Although a significant range of baselines variations and optimal cut-off values was observed, the predictive value of PPV and SVV from all the monitors was only moderate and comparable. Nevertheless, ΔPPV and ΔSVV appear to be a reliable and device-independent markers of FR.
- Publikační typ
- časopisecké články MeSH
- MeSH
- klinická studie jako téma MeSH
- lidé MeSH
- nemocnice fakultní * organizace a řízení MeSH
- výzkum MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- rozhovory MeSH
COVID-19 manifestation is associated with a strong immune system activation leading to inflammation and subsequently affecting the cardiovascular system. The objective of the study was to reveal possible interconnection between prolongated inflammation and the development or exacerbation of long-term cardiovascular complications after COVID-19. We investigated correlations between humoral and cellular immune system markers together with markers of cardiovascular inflammation/dysfunction during COVID-19 onset and subsequent recovery. We analyzed 22 hospitalized patients with severe COVID-19 within three timepoints (acute, 1 and 6 months after COVID-19) in order to track the impact of COVID-19 on the long-term decline of the cardiovascular system fitness and eventual development of CVDs. Among the cytokines dysregulated during COVID-19 changes, we showed significant correlations of IL-18 as a key driver of several pathophysiological changes with markers of cardiovascular inflammation/dysfunction. Our findings established novel immune-related markers, which can be used for the stratification of patients at high risk of CVDs for further therapy.
- Publikační typ
- časopisecké články MeSH
V současnosti je u pacientů s oběhovým selháním při tekutinové resuscitaci preferován koncept předpovědi tzv. fluid responsiveness (Fresp), tedy schopnosti odhadnout, zda srdce odpoví na tekutinovou výzvu zvýšením srdečního výdeje. Mezi hemodynamické parametry používané k předpovědi Fresp patří variace tepového objemu (stroke volume variation – SVV) a variace pulzního tlaku (pulse pressure variation – PPV), jejichž spolehlivost již potvrdila řada klinických studií. Především v prostředí intenzivní péče, ale také na operačním sále, se setkáváme s mnoha stavy, které činí interpretaci PPV/SVV nespolehlivou či zcela nemožnou. Prvním úskalím může být již volba monitorovací techniky, kdy mezi jednotlivými přístroji existují rozdíly jak ve spolehlivosti měření, tak ve výši ideálních prahových hodnot. Dobře prozkoumanými limitujícími faktory jsou vliv malého dechového objemu nebo nízká plicní compliance, které se ale dají efektivně překonat pomocí tzv. tidal volume challenge, tedy dočasným zvýšením dechového objemu. Naproti tomu spontánní dechová aktivita použití PPV/SVV zcela vylučuje. Jasný závěr zatím nepanuje v otázce falešné pozitivity PPV/SVV u pacientů s pravostrannou srdeční dysfunkcí. V případě levostranné dysfunkce je prediktivní hodnota PPV/SVV zřejmě nižší než u zdravých jedinců, v klinické praxi je ale metoda stále využitelná. Studie zabývající se intraabdominální hypertenzí zatím přináší konfliktní výsledky, zdá se ale, že navyšování nitrobřišního tlaku vede také k nutnosti navýšení ideálních prahových hodnot. Také změna variace po podání tekutinové výzvy (ΔPPV/ΔSVV) se jeví slibným nástrojem k ověření účinku tekutinové terapie.
The concept of prediction of fluid responsiveness - the ability of the heart to increase cardiac output in a response to a fluid bolus, has become a popular choice to guide fluid resuscitation in case of circulatory failure. Stroke volume variation (SVV) and pulse pressure variation (PPV) are dynamic parameters frequently used to predict fluid responsiveness that have been shown to be accurate in a number of studies. In the operating theatre, but mainly in the setting of intensive care unit, there are multiple factors that decrease PPV/SVV reliability or make their use even impossible. Firstly, the choice of monitoring technique can influence PPV/SVV values and optimal threshold values can differ among various devices. Low tidal volume and low pulmonary compliance are limiting factors that have been studied thoroughly and can be overcome with a tidal volume challenge - a temporary increase in tidal volume for the sole purpose of taking reliable PPV/SVV measurements. On the other hand, PPV/SVV evaluation remains useless in patients with spontaneous breathing activity. There are not enough data to draw conclusions in case of false-positivity of PPV/SVV in patients suffering from right ventricular failure. PPV/SVV performance is probably weakened, yet good enough, for clinical practice in patients with left ventricular failure. Studies on intraabdominal hypertension have reported conflicting results; nevertheless, the ideal threshold values tend to be higher during elevated intraabdominal pressure. The change in variation after fluid challenge (ΔPPV/ΔSVV) appears a useful tool to validate fluid administration efficacy.
- MeSH
- dechový objem MeSH
- komorová dysfunkce patofyziologie MeSH
- krevní tlak * MeSH
- lidé MeSH
- minutový srdeční výdej MeSH
- monitorování fyziologických funkcí metody přístrojové vybavení MeSH
- nitrobřišní hypertenze MeSH
- poddajnost plic MeSH
- tekutinová terapie metody MeSH
- tepový objem * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
- přehledy MeSH
Acute kidney injury (AKI) is associated with impaired outcomes in critically ill COVID-19 patients. However, the prognostic significance of early AKI is poorly described. We aimed to determine whether AKI on admission to the intensive care unit (ICU) and its development within the first 48 h predict the need for renal replacement therapy (RRT) and increased mortality. An analysis of 372 patients with COVID-19 pneumonia requiring mechanical ventilation without advanced chronic kidney disease from 2020 to 2021 was performed. The AKI stages on ICU admission and Day 2 were determined using adapted KDIGO criteria. The early development of renal function was assessed by the change in AKI score and the Day-2/Day-0 creatinine ratio. Data were compared between three consecutive COVID-19 waves and with data before the pandemic. Both ICU and 90-day mortality (79% and 93% vs. 35% and 44%) and the need for RRT increased markedly with advanced AKI stage on ICU admission. Similarly, an early increase in AKI stage and creatinine implied highly increased mortality. RRT was associated with very high ICU and 90-day mortality (72% and 85%), even surpassing that of patients on ECMO. No difference was found between consecutive COVID-19 waves, except for a lower mortality in the patients on RRT in the last omicron wave. Mortality and need for RRT were comparable in the COVID-19 and pre-COVID-19 patients, except that RRT did not increase ICU mortality in the pre-COVID-19 era. In conclusion, we confirmed the prognostic significance of both AKI on ICU admission and its early development in patients with severe COVID-19 pneumonia.
- MeSH
- akutní poškození ledvin * etiologie terapie MeSH
- COVID-19 * komplikace terapie MeSH
- jednotky intenzivní péče MeSH
- kreatinin MeSH
- kritický stav MeSH
- lidé MeSH
- náhrada funkce ledvin MeSH
- prognóza MeSH
- retrospektivní studie MeSH
- umělé dýchání MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
INTRODUCTION: Post-operative oxygen therapy is used to prevent hypoxemia and surgical site infection. However, with improvements of anesthesia techniques, post-operative hypoxemia incidence is declining and the benefits of oxygen on surgical site infection have been questioned. Moreover, hyperoxemia might have adverse effects on the pulmonary and cardiovascular systems. We hypothesized hyperoxemia post thoracic surgery is associated with post-operative pulmonary and cardiovascular complications. METHODS: Consecutive lung resection patients were included in this post-hoc analysis. Post-operative pulmonary and cardiovascular complications were prospectively assessed during the first 30 post-operative days, or hospital stay. Arterial blood gases were analyzed at 1, 6 and 12 h after surgery. Hyperoxemia was defined as arterial partial pressure of oxygen (PaO2)>100 mmHg. Patients with hyperoxemia duration in at least two adjacent time points were considered as hyperoxemic. Student t-test, Mann-Whitney U test and two-tailed Fisher exact test were used for group comparison. P values < 0.05 were considered statistically significant. RESULTS: Three hundred sixty-three consecutive patients were included in this post-hoc analysis. Two hundred five patients (57%), were considered hyperoxemic and included in the hyperoxemia group. Patients in the hyperoxemia group had significantly higher PaO2 at 1, 6 and 12 h after surgery (p < 0.05). Otherwise, there was no significant difference in age, sex, comorbidities, pulmonary function tests parameters, lung surgery procedure, incidence of post-operative pulmonary and cardiovascular complications, intensive care unit and hospital length of stay and 30-day mortality. CONCLUSION: Hyperoxemia after lung resection surgery is common and not associated with post-operative complications or 30-day mortality.
- Publikační typ
- časopisecké články MeSH
BACKGROUND: Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors is a rare, relatively new and potentially fatal clinical entity, characterized by metabolic acidosis with normal or only moderately elevated glycemia. The mechanisms are not fully understood but involve increased ketogenesis and complex renal metabolic dysfunction, resulting in both ketoacidosis and hyperchloremic acidosis. We report a rare case of fatal empagliflozin-associated acidosis with profound hyperchloremia and review its pathogenesis. CASE PRESENTATION: A patient with type 2 diabetes mellitus treated with empagliflozin underwent an elective hip replacement surgery. Since day 4 after surgery, he felt generally unwell, leading to cardiac arrest on the day 5. Empagliflozin-associated euglycemic diabetic ketoacidosis with severe hyperchloremic acidosis was identified as the cause of the cardiac arrest. CONCLUSIONS: This unique case documents the possibility of severe SGLT2 inhibitor-associated mixed metabolic acidosis with a predominant hyperchloremic component. Awareness of this possibility and a high index of suspicion are crucial for correct and early diagnosis.
- MeSH
- acidóza * chemicky indukované komplikace MeSH
- diabetes mellitus 2. typu * komplikace farmakoterapie MeSH
- diabetická ketoacidóza * diagnóza MeSH
- glifloziny * škodlivé účinky MeSH
- lidé MeSH
- srdeční zástava * MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
INTRODUCTION: According to the guidelines for preoperative assessment of lung resection candidates, patients with normal forced expiratory volume in 1 s (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) are at low risk for post-operative pulmonary complications (PPC). However, PPC affect hospital length of stay and related healthcare costs. We aimed to assess risk of PPC for lung resection candidates with normal FEV1 and DLCO (>80% predicted) and identify factors associated with PPC. METHODS: 398 patients were prospectively studied at two centres between 2017 and 2021. PPC were recorded from the first 30 post-operative days. Subgroups of patients with and without PPC were compared and factors with significant difference were analysed by uni- and multivariate logistic regression. RESULTS: 188 subjects had normal FEV1 and DLCO. Of these, 17 patients (9%) developed PPC. Patients with PPC had significantly lower pressure of end-tidal carbon dioxide (PETCO2 ) at rest (27.7 versus 29.9; p=0.033) and higher ventilatory efficiency (V'E/V'CO2 ) slope (31.1 versus 28; p=0.016) compared to those without PPC. Multivariate models showed association between resting PETCO2 (OR 0.872; p=0.035) and V'E/V'CO2 slope (OR 1.116; p=0.03) and PPC. In both models, thoracotomy was strongly associated with PPC (OR 6.419; p=0.005 and OR 5.884; p=0.007, respectively). Peak oxygen consumption failed to predict PPC (p=0.917). CONCLUSIONS: Resting PETCO2 adds incremental information for risk prediction of PPC in patients with normal FEV1 and DLCO. We propose resting PETCO2 be an additional parameter to FEV1 and DLCO for preoperative risk stratification.
- Publikační typ
- časopisecké články MeSH
Heparin-induced thrombocytopenia is a life-threatening immune-mediated complication of unfractionated heparin therapy. Fondaparinux is a therapeutic alternative, but it has limited evidence for its use in patients on extracorporeal membrane oxygenation (ECMO). We present a series of three adult patients with COVID-19 on ECMO who were diagnosed with heparin-induced thrombocytopenia after 7-12 days of unfractionated heparin treatment and were switched to fondaparinux. Fondaparinux was initiated with an intravenous loading dose of 5 mg, followed by a dose of 2.5 mg subcutaneously every 8-12 h. Dosage was adjusted according to daily measured anti-Xa concentration with a target range of 0.4-0.7 mg/L. The total duration of treatment with fondaparinux and ECMO ranged from 13 to 26 days. One major bleeding episode unrelated to fondaparinux therapy was observed, and the transfusions requirement was also low in all patients. The ECMO circuit was changed once in each patient. This series provides a deep insight into the use of fondaparinux over an extended period of time in patients on ECMO. Based on the presented data, fondaparinux can be considered a reasonable and affordable anticoagulant in patients without a high risk of bleeding.
- Publikační typ
- kazuistiky MeSH
