Background: Chest drain (CD) migration in the pleural cavity may result in inadequate drainage of pneumothorax. The aim of this study was to assess several parameters that might help in diagnosing CD migration on chest X-ray (CXR). Methods: Patients with a CD inserted from the safe triangle with a subsequent supine CXR and CT scan performed less than 24 hours apart were assessed for CD foreshortening, angle of inclination of the CD, and CD tortuosity. CD foreshortening was expressed as a ratio between CD length measured in coronal plane only and CD length inside the pleural cavity measured on CT. The angle of inclination of the CD was measured as the angle between the horizontal line and CD at the pleural space entry on CXR. CD tortuosity was calculated as a ratio between the distance from CD pleural space entry to the tip of the CD and the length of CD from the pleural space entry to its tip on CXR. Results: Altogether 28 patients were included in the study. The median time between the CXR and CT examinations was 5.4 hours (IQR, 3.8-6.9 hours). CD foreshortening was the best clue of a misplaced CD with AUC of 0.93, 100% sensitivity and 88% specificity for a cut-off value of 82%. The angle of CD inclination was greater in patients with misplaced CD with AUC of 0.83, 75% sensitivity and 92% specificity for a cut-off of 50 degrees. The performance of CD tortuosity was poor. Conclusions: Greater foreshortening of the CD and a steep angle of inclination of the CD above the horizontal at chest entry should raise suspicion of CD migration and mandate further investigation by chest ultrasound to rule out residual pneumothorax occult on CXR.
- Publikační typ
- časopisecké články MeSH
BACKGROUND: The regional citrate anticoagulation (RCA) induces changes in total (Catot) and ionized (Ca2+) calcium. As of now, we do not have much information about parallel changes of total (Mgtot) and ionized (Mg2+) magnesium. METHODS: The authors compared changes of Mg2+ and Mgtot with changes of Ca2+ and Catot in 32 critically ill patients on 4% trisodium citrate (4% TSC) with calcium-free fluids. RESULTS: The median continuous venovenous hemodiafiltration balance of Mgtot was -0.91 (-1.18 to -0.53) mmol/h compared to the median balance of Catot 0.86 (0.08-1.55) mmol/h. Postfilter Mg2+ decreased by 68.3% (70.8-65.6) in parallel (r = 0.41, p = 0.03) to decrease of postfilter Ca2+ (by 70.2% (73.0-66.1)) and was significantly related to the postfilter Ca2+ (r = 0.50, p < 0.001). The decrease of prefilter to postfilter Ca2+ correlated to a dosage of 4% TSC per blood flow (r = 0.37, p = 0.04). CONCLUSIONS: The loss of Mgtot during RCA is not covered by magnesium concentration in ordinary dialysis/substitution fluid and may lead to the depletion of total body magnesium. The postfilter Mg2+ is significantly related to the postfilter Ca2+. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi = 440972.
- MeSH
- akutní poškození ledvin krev patologie terapie MeSH
- antikoagulancia aplikace a dávkování škodlivé účinky MeSH
- citráty aplikace a dávkování škodlivé účinky MeSH
- hemodiafiltrace * MeSH
- hemofiltrace MeSH
- hořčík krev MeSH
- jednotky intenzivní péče MeSH
- kationty dvojmocné MeSH
- kritický stav MeSH
- lidé středního věku MeSH
- lidé MeSH
- nedostatek hořčíku krev etiologie patologie MeSH
- prospektivní studie MeSH
- senioři MeSH
- tekutinová terapie škodlivé účinky metody MeSH
- umělé dýchání MeSH
- vápník krev MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
BACKGROUND: The requirements for magnesium (Mg) supplementation increase under regional citrate anticoagulation (RCA) because citrate acts by chelation of bivalent cations within the blood circuit. The level of magnesium in commercially available fluids for continuous renal replacement therapy (CRRT) may not be sufficient to prevent hypomagnesemia. METHODS: Patients (n = 45) on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min) with RCA modality (4% trisodium citrate) using calcium free fluid with 0.75 mmol/l of Mg with additional magnesium substitution were observed after switch to the calcium-free fluid with magnesium concentration of 1.50 mmol/l (n = 42) and no extra magnesium replenishment. All patients had renal indications for CRRT, were treated with the same devices, filters and the same postfilter ionized calcium endpoint (<0.4 mmol/l) of prefilter citrate dosage. Under the high level Mg fluid the Qb, dosages of citrate and CRRT were consequently escalated in 9h steps to test various settings. RESULTS: Median balance of Mg was -0.91 (-1.18 to -0.53) mmol/h with Mg 0.75 mmol/l and 0.2 (0.06-0.35) mmol/h when fluid with Mg 1.50 mmol/l was used. It was close to zero (0.02 (-0.12-0.18) mmol/h) with higher blood flow and dosage of citrate, increased again to 0.15 (-0.11-0.25) mmol/h with 3,000 ml/h of high magnesium containing fluid (p<0.001). The arterial levels of Mg were mildly increased after the change for high level magnesium containing fluid (p<0.01). CONCLUSIONS: Compared to ordinary dialysis fluid the mildly hypermagnesemic fluid provided even balances and adequate levels within ordinary configurations of CRRT with RCA and without a need for extra magnesium replenishment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01361581.
- MeSH
- antikoagulancia chemie MeSH
- citráty chemie MeSH
- dialýza ledvin MeSH
- dialyzační roztoky chemie MeSH
- dospělí MeSH
- hemofiltrace škodlivé účinky MeSH
- homeostáza MeSH
- hořčík chemie metabolismus MeSH
- kritický stav MeSH
- kyselina citronová MeSH
- ledviny metabolismus MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- prospektivní studie MeSH
- renální insuficience terapie MeSH
- senioři MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS: The setting was an academic tertiary hospital. PARTICIPANTS: Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION: Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES: Adverse events from any cause during postoperative hospital stay were compared. RESULTS: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.
- MeSH
- dospělí MeSH
- glukosa aplikace a dávkování terapeutické užití MeSH
- intravenózní infuze MeSH
- inzulin aplikace a dávkování terapeutické užití MeSH
- jednoduchá slepá metoda MeSH
- kardiochirurgické výkony škodlivé účinky metody statistika a číselné údaje MeSH
- krevní glukóza účinky léků metabolismus MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- nemoci srdce epidemiologie chirurgie MeSH
- perioperační péče metody MeSH
- pooperační komplikace krev epidemiologie prevence a kontrola MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
Látky blokující beta-1-adrenergní receptory jsou široce užívané u pacientů s ischemickou chorobou srdeční, u pacientů se srdečním selháním. Anesteziolog se s nimi setkává v medikací pacientů podstupujících chirurgický výkon v anestezii. U vysoce rizikových pacientů byl prokázán příznivý vliv na dlouhodobou perioperační mortalitu. Esmolol, jako zástupce ultrakrátce působících betablokátorů, lze, podle dosud dostupných dat, bezpečně použít pro ochranu myokardu u pacientů se septickou tachykardií i přes nutnost aplikace katecholaminové podpory. V perioperačním období lze esmolol užít pro krátkodobé účelné omezení hemodynamiky, např. u pacientů s feochromocytomem. U kardiochirurgických pacientů vedlo jejich podání k lepší postreperfuzní adaptaci myokardu. Článek přehledně hodnotí jednotlivé indikace s důrazem na aplikaci esmololu u septických pacientů, již dříve publikovaných autory.
Beta-1-adrenergic blocking agents are widely used in patients with ischaemic heart disease and patients with heart failure. Anaesthesiologists are in daily contact with these drugs as they are part of medication in anaesthetised patients undergoing surgical procedures. Long-term mortality benefit effect of these drugs has been proven. Esmolol as a representative of ultrashort-acting beta-blockers can be safely used to control septic tachycardia and promote myocardial protection in this situation. According to published data it can be used even if a patient has concomitant catecholamine infusion. In the peri-operative period, esmolol is indicated for short time haemodynamic suppression, for example in patients undergoing pheochromocytoma resection. In cardiac surgical patients, peri-operative infusion of esmolol led to better post-reperfusion myocardial adaptation. This article reviews the indications for esmolol with special attention to its use in septic patients.
- MeSH
- anestezie metody MeSH
- anesteziologie MeSH
- antagonisté beta-1-adrenergních receptorů * aplikace a dávkování terapeutické užití MeSH
- beta blokátory * aplikace a dávkování terapeutické užití MeSH
- echokardiografie MeSH
- hemodynamika * účinky léků MeSH
- ischemická choroba srdeční prevence a kontrola MeSH
- kardiochirurgické výkony MeSH
- krevní tlak účinky léků MeSH
- lidé MeSH
- modely nemocí na zvířatech MeSH
- myokard MeSH
- noradrenalin MeSH
- oxid dusnatý MeSH
- perioperační péče * metody MeSH
- pilotní projekty MeSH
- propanolaminy * aplikace a dávkování terapeutické užití MeSH
- randomizované kontrolované studie jako téma MeSH
- resuscitační péče MeSH
- riziko MeSH
- sepse farmakoterapie komplikace MeSH
- septický šok farmakoterapie MeSH
- sinusová tachykardie * farmakoterapie MeSH
- srdce * patofyziologie účinky léků MeSH
- srdeční frekvence * účinky léků MeSH
- statistika jako téma MeSH
- tachykardie farmakoterapie MeSH
- zvířata MeSH
- Check Tag
- lidé MeSH
- zvířata MeSH
- Publikační typ
- práce podpořená grantem MeSH
- MeSH
- antagonisté beta-1-adrenergních receptorů aplikace a dávkování MeSH
- lidé MeSH
- noradrenalin aplikace a dávkování MeSH
- propanolaminy aplikace a dávkování MeSH
- septický šok farmakoterapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- dopisy MeSH
- komentáře MeSH
- práce podpořená grantem MeSH
BACKGROUND: Testing metabolic effects of a novel calcium-free, magnesium, phosphate and lactate containing solution (Lactocitrate) in combination with citrate anticoagulation. METHODS: Patients on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min, trisodium citrate (4% TSC)) with arterial lactate <3 mmol/l were included. At start, bicarbonate-buffered fluid was changed to Lactocitrate and the substitution of magnesium and phosphorus ceased. At 9 h the Qb was increased to 150 ml/min. At 18 h the CRRT dosage was increased to 3,000 ml/h. RESULTS: In 22 CVVHDF patients and another 23 on CVVH the pH, aHCO3 and Na (all p > 0.05) showed no significant changes regardless of the increased dosage of 4% TSC at 9 h (p < 0.001). Mgtot and phosphorus stabilised within normal range. Arterial lactate increased to 1.9 (1.6-2.6) mmol/l at 3,000 ml/h, p < 0.001). Citrate- and lactate-related energetic gains were up to 74 (61-86) kJ/h. CONCLUSIONS: The fluid performed well within ordinary CRRT dosage and Qb up to 150 ml/min. Lactate levels mildly increased and no magnesium and phosphorus replenishments were necessary.
- MeSH
- antikoagulancia aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- energetický metabolismus účinky léků MeSH
- glukosa škodlivé účinky terapeutické užití MeSH
- hemodiafiltrace MeSH
- hemodialyzační roztoky škodlivé účinky chemie terapeutické užití MeSH
- hemofiltrace * MeSH
- klinické křížové studie MeSH
- krevní glukóza analýza MeSH
- laktáty krev MeSH
- laktosa škodlivé účinky terapeutické užití MeSH
- lékové interakce MeSH
- lidé středního věku MeSH
- lidé MeSH
- náhrada léků MeSH
- nedostatek hořčíku chemicky indukované prevence a kontrola MeSH
- prospektivní studie MeSH
- pufry MeSH
- renální insuficience krev terapie MeSH
- senioři MeSH
- spotřeba kyslíku účinky léků MeSH
- studie proveditelnosti MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
PURPOSE: To determine bioenergetic gain of 2 different citrate anticoagulated continuous hemodiafiltration (CVVHDF) modalities and a heparin modality. MATERIALS AND METHODS: We compared the bio-energetic gain of citrate, glucose and lactate between 29 patients receiving 2.2% acid-citrate-dextrose with calcium-containing lactate-buffered solutions (ACD/Ca(plus)/lactate), 34 on 4% trisodium citrate with calcium-free low-bicarbonate buffered fluids (TSC/Ca(min)/bicarbonate), and 18 on heparin with lactate buffering (Hep/lactate). RESULTS: While delivered CVVHDF dose was about 2000 mL/h, total bioenergetic gain was 262 kJ/h (IQR 230-284) with ACD/Ca(plus)/lactate, 20 kJ/h (8-25) with TSC/Ca(min)/bicarbonate (P < .01) and 60 kJ/h (52-76) with Hep/lactate. Median patient delivery of citrate was 31.2 mmol/h (25-34.7) in ACD/Ca(plus)/lactate versus 14.8 mmol/h (12.4-19.1) in TSC/Ca(min)/bicarbonate groups (P < .01). Median delivery of glucose was 36.8 mmol/h (29.9-43) in ACD/Ca(plus)/lactate, and of lactate 52.5 mmol/h (49.2-59.1) in ACD/Ca(plus)/lactate and 56.1 mmol/h (49.6-64.2) in Hep/lactate groups. The higher energy delivery with ACD/Ca(plus)/lactate was partially due to the higher blood flow used in this modality and the calcium-containing dialysate. CONCLUSIONS: The bioenergetic gain of CVVHDF comes from glucose (in ACD), lactate and citrate. The amount substantially differs between modalities despite a similar CVVHDF dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a higher blood flow. When calculating nutritional needs, we should account for the energy delivered by CVVHDF.
- MeSH
- akutní poškození ledvin terapie MeSH
- antikoagulancia škodlivé účinky ekonomika farmakologie MeSH
- citráty škodlivé účinky ekonomika farmakologie MeSH
- dialyzační roztoky škodlivé účinky ekonomika farmakologie MeSH
- energetický metabolismus účinky léků MeSH
- energetický příjem účinky léků MeSH
- hemodiafiltrace škodlivé účinky ekonomika metody MeSH
- heparin škodlivé účinky ekonomika farmakologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- náklady na zdravotní péči MeSH
- prospektivní studie MeSH
- vodní a elektrolytová nerovnováha etiologie prevence a kontrola MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky kontrolované MeSH
- práce podpořená grantem MeSH
- srovnávací studie MeSH
BACKGROUND: There are limited data on systemic delivery of metabolic substrates during citrate anticoagulation. The direct citrate measurements are usually not available. METHODS: Patients on 2.2% acid-citrate-dextrose (ACD, n = 41) were compared to a control group on unfractionated heparin (n = 17). All were treated on 1.9-m(2) polysulfone filters. Samples were taken from the central venous catheter, ports pre- and post-filter and from effluent. RESULTS: The gain of citrate in CVVH (n = 18) was not different from CVVHDF (n = 23, p = 0.8). Mean gain of citrate was 25.4 ± 6.4 mmol/h. The systemic loads of lactate (p = 0.12) and glucose (p = 0.23) in CVVH were similar to CVVHDF. Mean inputs of lactate and glucose were 62.9 ± 21.1 and 26.6 ± 10.4 mmol/h, respectively. The mean difference between post- and prefilter unmeasured anions (d-UA) correlated with mean difference of citrate concentrations (p < 0.0001, r(2) = 0.66). The estimated caloric load of the citrate modalities was 5,536 ± 1,385 kJ/ 24 h. CONCLUSIONS: ACD might represent a significant load of metabolic substrates, particularly if used with lactate buffer. Systemic delivery of citrate can be predicted using d-UA in the extracorporeal circuit.
- MeSH
- akutní poškození ledvin terapie MeSH
- antikoagulancia metabolismus terapeutické užití MeSH
- design vybavení MeSH
- glukosa analogy a deriváty metabolismus terapeutické užití MeSH
- heparin terapeutické užití MeSH
- kyselina citronová metabolismus terapeutické užití MeSH
- kyselina mléčná metabolismus MeSH
- lidé MeSH
- náhrada funkce ledvin přístrojové vybavení metody MeSH
- prospektivní studie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- srovnávací studie MeSH
