Dariusz Onichimowski

The differences between two selected intensive care units located in central and northern Europe preliminary observation

BACKGROUND The aim of this study was to evaluate possible differences in the functioning of two selected intensive care units in Poland and Finland. The activity of the units was analysed over a period of one year. METHODS The following parameters were compared: demography of treated populations, site of admission, category of illness, severity of illness (APACHE-II scale), mean length of stay, demanded workload (TISS-28 scale), mortality (both ICU and hospital) and standardized mortality ratio (SMR). RESULTS The results of this study indicated that most of the patients in the Polish ICU, regardless of age, diagnosis and APACHE II score, presented significantly longer lengths of stay (14.65 ± 13.6 vs 4.1 ± 4.7 days, P = 0.0001), higher mean TISS-28 score (38.9 ± 9.1 vs 31.2 ± 6.1, P = 0.0001) and higher ICU and hospital mortality (41.5% vs 10.2% and 44.7% vs 21.8%, respectively, P = 0.0001). The values of SMR were 0.9 and 0.85 for the Finnish and Polish ICUs, respectively. CONCLUSION The collected data indicate huge differences in the utilisation of critical care resources. Treatment in Polish ICU is concentrated on much more severely ill patients which might be sometimes accompanied by futility of care. In order to verify and correctly interpret the presented phenomena, further studies are needed.

Prospective assessment of standardized mortality ratio (SMR) as a measure of quality of care in intensive care unit — a single-centre study

BACKGROUND The standardized mortality ratio (SMR) is a recognized indicator of critical care quality. This ratio is used to compare actual hospital mortality of all patients treated in a Intensive Care Unit (ICU) with predicted mortality. The aim of the study was prospective analysis of SMR as a measure of quality of care in single ICU. METHOD Prospective study was performed during the period of 12 months in ICU of Czerniakowski Hospital in Warsaw. Predicted hospital mortality was calculated using the SAPS 3 model. The value of SMR was evaluated in the three risk groups (low, moderate, high risk) and included patients surgical status (nonoperative, after elective and emergency surgery). RESULTS A total of 341 patients were included. SMR in general population was 0,98 (95% CI 0,74-1,28). In the low and high-risk groups the value of SMR did not differ significantly from 1. In the average risk group as well as patients undergoing elective surgery, the value of SMR tended to exceed 1. CONCLUSIONS In groups of patients with low and high risk the values of SMR indicated favourable quality of care. Study results should prompt to carry out detailed analysis of the course of treatment of patients at average risk of death. Analysis of the course of treatment and qualification criteria for surgery in patients undergoing elective surgery is also indicated.

Pulmonary rehabilitation within intensive care units exemplified by traffic collisions casualties

Abstract Introduction The early introduction of a rehabilitation procedure is of vital importance in the process of acting upon the respiratory system. In comprehensive therapy, pulmonary rehabilitation is perceived as an integral part of treatment for mechanically ventilated patients. Aim The aim of this work was to conduct a comparative analysis of pulmonary rehabilitation concerning patients who had sustained an injury as the result of traffic collisions, and were subsequently treated in an intensive care unit (ICU). Materials and Methods Research material consisted of information contained in the medical documentation of 43 patients, ranging in ages from 15 to 57 years, treated in the ICU for injuries sustained during traffic collisions. This analysis involved the values of the parameters recorded first on admission of the patient to the unit, and then every 7 days thereafter, and finally upon discharge from the ICU, and included: arterial blood gasometry, pulsoxymetry, capnometry, body temperature, arterial blood pressure, and pulse rate. Results and Discussion Pneumonia occurred most frequently in patients ventilated mechanically during the period from the 15th to the 28th day of hospitalization and constituted 60% of the total occurring pneumonias. Deaths were observed more often in patients with acidosis and hypercapnia. Values of arterial oxygen saturation of hemoglobin (SaO2) below 94% were recorded in that group of patients for whom therapeutic procedures ended in failure (40%). For the remaining patients, SaO2 values exceeded 94%. The analysis of our material showed divergences concerning the values of partial pressure of end-tidal carbon dioxide (PetCO2) and partial pressure of carbon dioxide in the arterial blood (PaCO2). The mean values of SaO2 and percutaneous monitoring of hemoglobin oxygen saturation (SpO2) were similar. Conclusions The length of stay within the ICU is significant with respect to the occurrence of complications in the form of pneumonia. Patients whose parameter values were within the norm during pulmonary rehabilitation attained spontaneous respiration at discharge. SpO2 and PetCO2 are of vital importance in the pulmonary rehabilitation process, complemented by regularly taken arterial blood gasometry measurements.

Primary hyperparathyroidism in pregnancy — a diagnostic and therapeutic challenge

Hypercalcaemia during pregnancy is uncommon, and mostly associated with primary hyperparathyroidism (pHPT). If unrecognised, it poses a significant risk for the mother and the foetus. Maternal symptoms include: hyperemesis, muscle weakness, pancreatitis, nephrolithiasis, bone disease, mental status changes, and hypercalcaemic crisis. Untreated disease complicates foetal development and foetal death is a significant risk. Our case illustrates the difficulty in detecting pHPT during pregnancy, serious complications connected with severe hypercalcaemia, and difficulties in preparing the patient for surgical treatment. Our review of the medical literature did not identify any previous case of a pregnant woman with hypercalcaemic crisis (total calcium 17 mg/dL, parathyroid hormone 2302 pg/mL), acute pancreatitis caused by pHPT, and with hyperthyroidism, who had undergone a successful surgical treatment.

Practical issues of nutrition during continuous renal replacement therapy

Continuous renal replacement therapy (CRRT) in critically ill patients has significant impact on ones ability to provide efficient nutritional therapy. CRRT may help in the prevention of intestinal oedema and the maintenance of the proper function of the gastrointestinal tract by enabling strict control of the fluid balance. It facilitates early introduction of nutrition via the enteral route, as well as allowing for the composition of high-volume feeding mixtures. It is necessary to take into consideration that during CRRT, together with blood purification of toxic substances, nutritive elements are also eliminated to some extent (micro- and macronutrients). In this article, the authors discuss the impact of CRRT on nutritive elements loss, energetic balance and present the principles of adjusting feeding prescriptions to changes implied by CRRT.

Evaluation of the effectiveness of the Quadratus Lumborum Block type I using ropivacaine in postoperative analgesia after a cesarean section — a controlled clinical study

OBJECTIVES Quadratus Lumborum Block in contrast to Transversus Abdominis Plane Block contains a unique component which not only stops somatic pain but also inhibits visceral pain by spreading the local anesthetic to the paravertebral space. This study was designed to determine whether performing the Quadratus Lumborum Block type I in patients un-dergoing cesarean section would be associated with both decreased morphine consumption and decreased pain levels in the postoperative 48-hour period. MATERIAL AND METHODS Sixty patients undergoing caesarean section under spinal anesthesia were randomly and equally assigned to one or other of two groups: QLB I (who received Bilateral Quadratus Lumborum Block type I with the use of 24 mL 0.375% ropivacaine per side) or a Control group. In both groups, on-demand morphine analgesia was administered postoperatively within the first 48 hours. The following were measured: the morphine consumption; the time elapsed from the C-section until the first dose of morphine; and the levels of pain intensity among patients in rest (numeral pain rating scale). RESULTS There were no statistically significant demographic data differences between the QLB I and Control groups. The following significant differences were observed in the 48-hour postoperative period: morphine consumption was higher in the Control group (p = 0.000); the time elapsed from the C-section until the first dose of morphine was longer in QLB I group (p < 0.05); and the median of the pain numeric rating scale was higher in the Control group (p < 0.05). CONCLUSIONS Quadratus Lumborum Block type I significantly reduces morphine consumption and pain levels up to 48 hours postoperatively.

Use of levosimendan in the treatment of cerebral vascular vasospasm: a case study

Despite the progress in the management of cerebral arterial aneurysms, subarachnoid hemorrhage (SAH) remains the major cause of neurological disability. While SAH-related deaths usually occur as a result of brain impairment due to hemorrhage, permanent neurological deficits are caused by cerebral ischemia due to edema and spasm of cerebral arteries. Additionally, ~20%–30% of patients with SAH develop secondary cardiomyopathy; this phenomenon is known as neurogenic stress cardiomyopathy (NSC), which is associated with increased mortality and poor long-term prognosis. Levosimendan is a new inotropic drug that causes calcium sensitization of troponin C, thus increasing contraction force of myofilaments. The drug also causes opening of ATP-dependent potassium channels in vascular smooth muscles, which results in dilatation of veins and arteries, including cerebral arteries. To date, there have been several reports of levosimendan application in patients with SAH and neurogenic stress cardiomyopathy, and the effect of the drug on vasospasm has been previously advocated. This paper presents a case report of a 57-year-old patient with massive SAH, where levosimendan was used for reducing vasospasm.

Possibilities of using ultrasound for diagnosis of invasive pulmonary mucormycosis – A case study

Abstract Introduction Mucormycosis is a rare but highly lethal fungal infection, usually affecting immunocompromised patients. Aim To present and analyze the diagnostic capabilities of transthoracic ultrasonography in invasive pulmonary mucormycosis. Case study We present a case involving a 41-year-old female patient with pneumonia complicated by multisystem organ failure, who was diagnosed with invasive pulmonary mucormycosis. Results and discussion Transthoracic ultrasonography (TUS) revealed a consolidation area of heterogeneous echostructure with an abnormal air bronchogram, possibly suggestive of an invasive pulmonary fungal disorder. The presence of lesions observed with TUS was confirmed by computed tomography (CT). The final diagnosis of mucormycosis was possible after Mucor species fungi were detected in bronchoalveolar lavage culture. Conclusions (1) TUS is a widely available and inexpensive diagnostic method that is characterized by the absence of adverse effects, and its applicability in the diagnosis of pulmonary disorders other than invasive fungal infections is well documented. (2) Ultrasonographic analysis of lesions facilitates differentiation between bacterial and fungal pneumonia, and the high sensitivity and specificity of the procedure compared to CT scans as a reference method supports the reliability of ultrasound scans in the diagnosis of invasive pulmonary aspergillosis (IPA). (3) The use of TUS in the diagnosis of invasive pulmonary mucormycosis appears warranted, particularly in cases when it is impossible to obtain a proven diagnosis. (4) Ultrasonographic diagnosis of invasive lung disorders, including mucormycosis, requires further studies.

A comparison of oral controlled-release morphine and oxycodone with transdermal formulations of buprenorphine and fentanyl in the treatment of severe pain in cancer patients

Aim of the study To compare analgesia and adverse effects during oral morphine and oxycodone and transdermal fentanyl and buprenorphine administration in cancer patients with pain. Patients and methods Cancer patients treated at home and in outpatient clinics with severe pain (numerical rating scale score 6–10) fail to respond to non-opioids and/or weak opioids. All patients were randomized to either morphine, oxycodone, fentanyl or buprenorphine and divided into subgroups with predominant neuropathic and nociceptive pain component. Doses of opioids were titrated to satisfactory analgesia and acceptable adverse effects intensity. Patients were assessed at baseline and followed for 28 days. In all patient groups, immediate-release oral morphine was the rescue analgesic and lactulose 10 mL twice daily was the prophylaxis of constipation; no antiemetics were used as prophylaxis. Results A total of 62 patients participated and 53 patients completed the study. Good analgesia was obtained for all 4 opioids, for both nociceptive and neuropathic pain. The use of co-analgesics was greater in patients with neuropathic pain. Morphine treatment was associated with less negative impact of pain on ability to walk, work and activity (trend) according to Brief Pain Inventory-Short Form scores and less consumption of rescue morphine. The most common adverse effects included nausea and drowsiness, which increased at the beginning of the treatment and gradually decreased over the days to come. Appetite, well-being, anxiety, depression, and fatigue improved. There was no constipation (the Bowel Function Index scores were within normal range) during the treatment with all opioids. No changes were seen for constipation, vomiting and dyspnea. Conclusion All opioids were effective and well-tolerated. Morphine was the most effective in the improvement in some of the Brief Pain Inventory-Short Form items regarding negative impact of pain on patients’ daily activities. Prophylaxis of constipation was effective; antiemetics may be considered for nausea prevention.

Incidence of in-hospital cardiac arrest in Poland

BACKGROUND In-hospital cardiac arrest with its poor prognosis is a challenging problem in hospitals. The aim of this study was to evaluate in Polish hospitals the frequency of in-hospital cardiac arrests with the subsequent mortality, with special emphasis on the type of unit at which the event occurred, and the patients demographic data, such as age and sex. METHODS The study was a retrospective analysis of data for 2012 registered in the Polish General Hospital Morbidity Study. This research covered all Polish hospitals, excluding only government and psychiatric hospitals. The study inclusion criterion was the incidence of cardiac arrest in any hospital ward, recorded by the respective ICD-10 diagnosis code. RESULTS Of the 7,775,553 patients hospitalized, the diagnosis of cardiac arrest was reported in a total of 22,602 patients, which included 22,317 adults (98.7% of all patients) and 285 children (1.3%). Overall mortality after cardiac arrest among adults was 74.2%, and in children 46.7%. In both absolute numbers and as percentages of all documented cases, cardiac arrests occurred most often at the departments of intensive care, internal medicine, cardiology and emergency medicine. The accompanying mortality was lower than average at the departments of intensive care, cardiology, cardiology high dependency unit and emergency medicine. The median age of patients with cardiac arrest who died in the hospital was higher than the median age of those who survived (72 vs. 64; P < 0.05). Although cardiac arrests were reported more often among men than women (58.2% vs. 41.8%; P < 0.001), the hospital mortality was higher among women (79.2% vs. 71.6%; P < 0.001). CONCLUSION The frequency of in-hospital cardiac arrests in Polish hospitals and the subsequent mortality is not substantially different from that observed in other countries. However, our study, based on ICD-10 diagnosis codes, gives only limited information about the patients and circumstances of this event. An in-depth analysis of the causes, prognoses, and outcome of in-hospital cardiac arrests could be facilitated by the creation of a national registry.