Juozas Ivaškevičius

Intensive care unit acquired infection: a prevalence and impact on morbidity and mortality

Background:  Severe infection is a common reason for intensive care and contributes to increased morbidity and mortality. The aim of the study was to determine the prevalence of infection among intensive care unit (ICU) patients and to evaluate the consequences of ICU‐acquired infection on morbidity and mortality.

Evaluation of intensive care unit performance in Lithuania using the SAPS II system

Background and objective: Outcome prediction and evaluation of intensive care unit (ICU) performance using severity of illness scoring is a tool for the estimation of effectiveness and quality of intensive care. We used the simplified acute physiology score (SAPS) II system to evaluate ICU performance. Methods: The present study is a prospective observational study in an ICU at Vilnius University Emergency Hospital, Lithuania. The observed death rate was compared with the predicted death rate calculated using SAPS II system. The ability of the SAPS II prognostic system to predict the probability of hospital mortality was assessed with discrimination and calibration measures. Results: Two-thousand-and-sixty-seven patients consecutively admitted to the ICU were studied. The median SAPS II score on the first ICU day was 29. The SAPS II system showed a good ability to separate those patients predicted to live from those predicted to die (an area under the receiver operating characteristic curve was 0.883). The calibration curve demonstrated under-prediction of the actual death rate (Hosmer-Lemeshow goodness-of-fit test, χ2 = 56.98; df = 8; P < 0.001). The observed mortality was higher than predicted by the SAPS II equation (observed to predicted ratio is 1.28). Conclusions: The SAPS II system is a useful tool for the assessment of ICU performance. This system demonstrated a good ability of discrimination, but an under-prediction of the actual mortality rate, in Lithuanian ICUs.

Impact of malnutrition on postoperative delirium development after on pump coronary artery bypass grafting.

Background & aimsEven though malnutrition is frequently observed in cardiac population outcome data after cardiac surgery in malnourished patients is very rare. No thorough research was done concerning the impact of malnutrition on neuropsychological outcomes after cardiac surgery. The aim of our study was to analyze the incidence of postoperative delirium development in malnourished patients undergoing on pump bypass grafting.MethodsWe performed a cohort study of adults admitted to Vilnius University Hospital Santariskiu Clinics for elective coronary artery bypass grafting. The nutritional status of the patients was assessed by Nutritional Risk Screening 2002 (NRS-2002) questionnaire the day before surgery. Patients were considered as having no risk of malnutrition when NRS-2002 score was less than 3 and at risk of malnutrition when NRS-2002 score was ≥3. During ICU stay patients were screened for postoperative delirium development using the CAM-ICU method. and divided into two groups: delirium and non delirium. The statistical analysis was preformed to evaluate the differences between the two independent groups. The logistic regression model was used to evaluate the potential preoperative and intraoperative risk factors of postoperative delirium.ResultsNinety-nine patients were enrolled in the study. Preoperative risk of malnutrition was detected in 24 % (n = 24) of the patients. The incidence of early postoperative delirium in overall study population was 8.0 % (n = 8). The incidence of the patients at risk of malnutrition was significantly higher in the delirium group (5 (62.5 %) vs 19 (20.9 %), p <0.0191). In multivariate logistic regression analysis risk of malnutrition defined by NRS 2002 was an independent preoperative and intraoperative risk factor of postoperative delirium after coronary artery bypass grafting (OR: 6.316, 95 % CI: 1.384-28.819 p = 0.0173).ConclusionsPreoperative malnutrition is common in patients undergoing elective coronary artery bypass grafting. Nutrition deprivation is associated with early postoperative delirium after on pump coronary artery bypass grafting.

Goal Directed Fluid Therapy Revised: Indirect Monitoring of Interstitial Fluid Accumulation During Mini Fluid Challenges with Crystalloids

Goal directed fluid therapy (GDT) implies administration of fluid boluses with the aim of optimizing cardiac performance. There is a major concern that maximization of cardiovascular performance can be achieved in expense of deterioration in body hydration processes. Also, these methods require semi invasive devices. However, monitoring of the whole body hydration status and interstitial fluid accumulation during fluid loading is not possible in everyday clinical practice. A new method, minimum Volume Loading Test (mVLT), uses evaluation of plasma dilution efficacy in small fluid boluses (2.5 - 5.0 ml kg -1 ) of isoosmotic crystalloid solutions followed by 5 min periods without fluids. The inva- sively measured arterial and venous hemoglobins, and simultaneous non-invasively measured hemoglobin (SpHb TM from Radical-7, Masimo inc., Irvine, USA) are used for estimation of plasma dilution which serves as an indication of plasma volume expansion. The objective of this paper was to discuss plasmadilution as a target parameter for goal directed therapy. Could plasma di- lution also indicate a degree of interstitial fluid accumulation?

A mini volume loading test for indication of preoperative dehydration in surgical patients.

BACKGROUND AND OBJECTIVE Previously, a mini volume loading test (mVLT) detected signs of dehydration in healthy volunteers after an overnight fast. Our objective was to investigate whether mVLT could indicate preoperative dehydration in patients after an overnight fast. MATERIALS AND METHODS The mVLT was performed in 36 elective primary total knee arthroplasty patients. Each subject received three fluid challenges before anesthesia induction. These consisted of 5 mL/kg boluses of Ringers acetate infused over 3-5 min and followed by a 5-min period without fluids. Invasive (arterial, venous) and noninvasive (capillary) measurements of hemoglobin concentration were performed before and after each fluid challenge, as well as after a 20-min period without fluids which followed the last bolus. Arterial, venous and capillary plasma dilutions were calculated in every data point. Dilution values were used to calculate the plasma dilution efficacy of each fluid challenge. RESULTS Venous dilution was higher than capillary after the first fluid challenge (P=0.030), but lower than capillary after 20 min period following the last bolus (P=0.009). Arterial dilution was lower than capillary (P=0.005) after 20 min following the last bolus. Veno-capillary and arterio-capillary plasma dilution efficacy differences decreased (P=0.004 and P=0.033, respectively) from positive to negative during mVLT. These are signs of re-hydration from pre-existing dehydration according to a transcapillary reflux model. CONCLUSIONS Signs of dehydration were observed during mVLT in patients after pre-operative overnight fast. A revised transcapillary reflux model was proposed to explain the results.

Asymptomatic carotid artery stenosis and cognitive outcomes after coronary artery bypass grafting.

Abstract Objective. Cognitive decline has a negative impact on early postoperative morbidity and affects subjective quality of life. The role of asymptomatic cerebrovascular disease in developing postoperative neurocognitive damage remains controversial. The aim of our study was to evaluate the impact of asymptomatic carotid artery stenosis on postoperative cognitive decline. Design. We investigated 127 patients undergoing coronary artery bypass grafting. The neuropsychological examination, including a cognitive battery of seven tests and two scales for evaluation of mood disorders, was conducted the day before surgery and before the discharge from hospital. Results. Early postoperative cognitive decline (POCD) was detected in 46% of patients. POCD was associated with longer duration of surgery (p = 0.02), low cardiac output syndrome perioperatively (p < 0.05), postoperative bleeding (p = 0.03), longer postoperative mechanical ventilation time and intensive care unit stay (p < 0.05). Carotid artery lesion was detected in 42 (68.8%) patients. Multivariate regression analysis showed that carotid artery stenosis of more than 50% was an independant predictor of POCD (OR 26.89, CI 6.44–112.34). Conclusions. Asymptomatic carotid artery stenosis is a risk factor for cognitive decline after coronary artery bypass grafting.

Preoperative risk factors of malnutrition for cardiac surgery patients

Background. Malnutrition (MN) is prevalent in cardiac surgery, but there are no specific preoperative risk factors of MN. The aim of this study is to assess the clinically relevant risk factors of MN for cardiac surgery patients. Materials and methods. The nutritional state of the patients was evaluated one day prior to surgery using a bioelectrical impedance analysis phase angle (PA). Two groups of patients were generated according to low PA: malnourished and well nourished. Risk factors of MN were divided into three clinically relevant groups: psychosocial and lifestyle factors, laboratory findings and disease-associated factors. Variables in each different group were entered into separate multivariate logistic regression models. Results. A total of 712 patients were included in the study. The majority of them were 65-year old men after a CABG procedure. Low PA was present in 22.9% (163) of patients. The analysis of disease-related factors of MN revealed the importance of heart functions (NYHA IV class OR: 3.073, CI95%: 1.416–6.668, p = 0.007), valve pathology (OR: 1.825, CI95%: 1.182–2.819, p = 0.007), renal insufficiency (OR: 4.091, CI95%: 1.995–8.389, p < 0.001) and body mass index (OR: 0.928, CI95%: 0.890–0.968, p < 0.001). Laboratory values related to MN were levels of haemoglobin (OR: 0.967, CI95%: 0.951–0.983, p < 0.001) and C-reactive protein (OR: 1.015, CI95%: 1.002–1.028, p = 0.0279). The lifestyle variables that qualified as risk factors concerned the intake of food (OR: 3.030, CI95%: 1.353–6.757, p = 0.007) and mobility (OR: 2.770, CI95%: 1.067–7.194, p = 0.036). Conclusions. MN risk factors comprise three different clinical groups: psychosocial and lifestyle factors, laboratory findings and disease-associated factors. The patients who are most likely to be malnourished are those with valve pathology, severe imparted heart function, insufficient renal function and high inflammatory markers. Also these patients have decreased mobility and food intake.

Noninvasive monitoring of hemoglobin (SpHbTM) during preoperative stepwise infusion of Ringerʼs acetate: accuracy for the evaluation of arterial plasma dilution: 3AP4-4

ference was found among areas under the ROC curves for ScvO2, rSO2b and rSO2s. Conclusion(s): rSO2b and rSO2s cannot be used to provide rapid and non invasive estimation of ScvO2 and trends in rSO2b and rSO2s cannot be considered as a non invasive surrogate for the trend in ScvO2 following cardiac surgery. ScvO2, rSO2b and rSO2s are of poor diagnostic value to predict fluid responsiveness in that set ting. References: 1. Crit Care 2007;11:R6 2. J Appl Physiol 2008;104:475-481

Intra-articular morphine or neostigmine does not assure better pain relief

Background and ObjectivesChoice of optimal postoperative analgesia technique remains challenging. Our double — blind randomized prospective clinical study compares efficacy of end-of- surgery intra-articular application of morphine or neostigmine after anterior crutiate ligament repair.Methods60 adult ASA I–II patients were randomized into 3 groups: intra-articular morphine 6 mg, neostigmine 0.5 mg, placebo. All received femoral nerve block and spinal anesthesia. Numeric rating scale used for pain assessment at rest and motion during 48 postoperative hours, and 0–10 scale for evaluation of overall patient satisfaction. Adjunct analgesics were recorded.ResultsThe only significant difference between protocol groups was better pain relief at motion at the end of trial in neostigmine 0.5 mg group than in placebo (p=0.018). Consumption of adjuncts wasn’t different on day of surgery, postoperative Day 1 and Day 2 respectively - diclofenac (p=0.85, p=0.41, p=0.9) and tramadol (p=0.62, p=0.72, p=1). Patient satisfaction was similar (p=0.59) among groups.ConclusionsIntra-articular neostigmine provided similar pain control at motion as morphine during the trial, but it was better than placebo on the 2nd postoperative day. Similar pain control at rest, adjunct consumption and patient satisfaction recorded throughout the whole observation period in all groups.

Hipotenzinė anestezija atliekant klubo ir kelio sąnarių endoprotezavimą: į tikslą nukreiptas skysčių terapijos algoritmas

Audrius Andrijauskas 1 , Juozas Ivaskevicius 1 , Manvilius Kocius 2 , Narūnas Porvaneckas 2 , Darius Cincikas 1 , Jeugenija Olsevska 1 1 Vilniaus universiteto Anesteziologijos ir reanimatologijos klinika, Siltnamių g. 29 LT-04130 Vilnius 2 Vilniaus universiteto Reumatologijos, ortopedijos, traumatologijos, plastinės ir rekonstrukcinės chirurgijos klinika, Siltnamių g. 29 LT-04130 Vilnius El pastas: Audrius.Andrijauskas@mf.vu.lt Kontroliuojama hipotenzinė anestezija jau ilgą laiką taikoma siekiant sumažinti kraujo netektį ir kraujo perpylimo poreikį. Be to, sumažinus arterinį kraujo spaudimą, pagerėja operavimo sąlygos („sausas operacinis laukas“). Atsiranda galimybė sumažinti isorinį mechaninį spaudimą, taikomą operuojamos galūnės kraujotakai sustabdyti atliekant kelio sąnario endoprotezavimą, arba net visai jo netaikyti. Siuolaikiniai metodai grindžiami įvairiais valdomą hipotenziją sukelianciais veiksniais, kaip pavyzdžiui, tai gali būti (a) kraujagysles pleciantys vaistai, (b) centrinė simpatinė blokada ir (c) stiprų kardiodepresinį-vazopleginį poveikį turintys inhaliaciniai anestetikai. Taikant hipotenzine anesteziją, didžiausią rūpestį kelia paciento saugumo užtikrinimas. Ypatingą pavojų kelia „nebyli“ organų isemija dėl nepakankamo jų aprūpinimo krauju, nes ji gali sutrikdyti audinių ir organų funkciją ar net sukelti žūtį. Taigi, užtikrinant metodo saugumą lemiama reiksmė tenka efektyvaus cirkuliuojancio tūrio (normovolemijos) palaikymui arterinės hipotenzijos sąlygomis. Deja, iki siol nėra paprasto, patikimo ir veiksmingo metodo, kuris leistų užtikrinti sią ypac svarbią paciento saugumo sąlygą. Tradicinius kraujotakos optimizavimo metodus siuo metu keicia skyscių terapijos metodai, grindžiami į tikslą nukreiptų priemonių taikymo koncepcija. Remdamiesi sia koncepcija autoriai sukūrė klinikinį TNP algoritmą, kuris skirtas normovolemijai užtikrinti, atliekant kelio ir klubo sanario planinį endoprotezavimą hipotenzinės anestezijos sąlygomis. Algoritmas pateikiamas kartu su svarbiausių hemodinamikos parametrų taikymo ir klinikinio interpretavimo ypatumų apžvalga. Reiksminiai žodžiai: hemodinamika, į tikslą nukreipta skyscių terapija, skysciai, transfuzija, algoritmas Hypotensive anaesthesia in total hip and knee arthroplasty: algorithm for the goal-directed fluid management Audrius Andrijauskas 1 , Juozas Ivaskevicius 1 , Manvilius Kocius 2 , Narūnas Porvaneckas 2 , Darius Cincikas 1 , Jeugenija Olsevska 1 1 Vilnius University Clinic of Anaesthesiology and Intensive Care, Siltnamių str. 29 LT-04130 Vilnius, Lithuania 2 Vilnius University Clinic of Rheumatology, Orthopaedics, Traumatology, Plastic and Reconstructive Surgery, Siltnamių str. 29, LT-04130 Vilnius, Lithuania E-mail: Audrius.Andrijauskas@mf.vu.lt Hypotensive anaesthesia is a technique that deploys the controlled reduction of mean arterial pressure. It has been used for decades to reduce intraoperative blood loss and related blood transfusions, also to ensure the ‘dry operating field’ and minimize the tourniquet inflation pressure in patients undergoing total hip (THA) and knee (TKA) arthroplasty. Hypotensive anesthesia can be achieved in different ways such as (a) by decreasing cardiac output with vasodilatory agents, (b) inducing the sympathetic block by spinal and/or epidural anaesthesia, and/or (c) by using potent anesthetic gases in general anaesthesia. The major concern in the method’s clinical applicability is the patient’s safety. Inherent risks related to hypotensive anaesthesia are mainly associated with the concern of occult tissue hypoperfusion resulting from inadequately compensated relative hypovolemia. Therefore, maintaining an effective circulating volume (normovolemia) is crucial for the safe management of controlled arterial hypotension. However, the lack of a simple, reliable and effective method for the guidance of appropriate measures is an ongoing deficiency. Conventional strategies aiming to establish, monitor and maintain normovolemia are currently replaced by the goal-directed management (GDM) in fluid therapy. It has already become a standard of care in selected patients such as those undergoing major abdominal surgery. On the basis of goal-directed fluid management, authors have developed a GDM algorithm for the optimization of fluid status, aiming to secure normovolemia during hypotensive anaesthesia. The new algorithm is highlighted along with a review of related issues of its clinical application. Key words: hemodynamics, goal-directed-management, fluid, transfusion, algorithm