M.H. Starczewska

Prognostic scoring systems for mortality in intensive care units — the APACHE model

The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system is time consuming. The mean time for introducing a patients data to APACHE IV is 37.3 min. Nevertheless, statisticians have known for years that the higher the number of variables the mathematical model describes, the more accurate the model. Because of the necessity of gathering data over a 24-hour period and of determining one cause for ICU admission, the system is troublesome and prone to mistakes. The evolution of the APACHE scoring system is an example of unfulfilled hopes for accurately estimating the risk of death for patients admitted to the ICU; satisfactory prognostic effects resulting from the use of APACHE II and III have been recently studied in patients undergoing liver transplantations. Because no increase in the predictive properties of successive versions has been observed, the search for other solutions continues. The APACHE IV scoring system is helpful; however, its use without prepared spreadsheets is almost impractical. Therefore, although many years have passed since its original publication, APACHE II or its extension APACHE III is currently used in clinical practice.

Perioperative bleeding in patients undergoing liver transplantation

Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years or so, significant progress in surgical techniques and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patients mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during LT have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.

Will transoesophageal echocardiography become a standard tool for anesthetists to assess haemodynamic status during non-cardiac surgeries? Case report and literature review.

A 53-year-old male, with no history of cardiovascular diseases, underwent elective extended right hemihepatectomy for large metastatic tumor. Approximately 2 hours after the start of procedure sudden onset of severe hypotension associated with profound desaturation and significant fall in end-tidal carbon dioxide pressure was noted. Transoesophageal echocardiography was performed and massive air embolism was confirmed. Patient was turned into Trendelenburg position, inspired oxygen was increased to 100% and positive end-expiratiory pressure turned up to 10 cm H20. Patient was further resuscitated with iv fluids, blood products and vasopressors under surveillance of transoesophageal echocardiography. In this report we present a case in which intraoperative use of transoesophageal echocardiography by trained anaesthetist helped to immediately identify the cause of sudden hypotension and hypoxaemia. Transoesophageal echocardiographywas also a valuable tool for direct monitoring of efficacy of instituted treatment.

Impact of genetic polymorphism on perioperative bleeding in adult patients undergoing liver transplantation

Intr Perioperative bleeding remains one of the major causes of increased mortality and morbidity in patients (pts) undergoing liver transplantation (LT). Only few studies have examined the association between genetic polymorphisms and increased blood loss in the population of surgical pts. There are no data regarding this issue neither in liver nor in any other solid organ transplant recipients.

Usability of ultrasound assessment of gastric content. Case reports

The paper presents the use of ultrasound assessment of gastric content in anesthesiological practice. Factors influencing pulmonary aspiration of gastric content and the risk of a complication in the form of aspiration pneumonia are discussed. The examination was performed on two patients hospitalized in a state of emergency who required surgical intervention. The first patient, a 46-year-old male with a phlegmon of the foot, treated for type 2 diabetes, ischemic heart disease and renal insufficiency, required urgent incision of the phlegmon. The second patient, a 36-year-old male with a post-traumatic pericerebral hematoma, qualified for an urgent trepanation. Interviews with the patients and their medical documentation indicated that they had been fasting for the recommended six hours before the surgery. However, during a gastric ultrasound examination it was found that food was still present in the stomach, which caused a change in the anesthesiological procedure chosen. The authors present a method of performing gastric ultrasound examination, determining the nature of the food content present and estimating its volume.

535 Effect of the optimal neurohormonal blockade on survival in high-risk patients groups with chronic heart failure

Background: It has been proven that modulation of the neurohormonaJ activation with beta-blockers (LBA), ACE-inhibitors (ACE-I) and spironolactone improve survival in patients (pts) with chronic heart failure (CHF). However in most of the trials pts from the high-risk groups were excluded, so there is still little evidence whether such therapy is beneficial for this subpopulations. Aim: The aim of this study was to estimate the effect of the optimal neurohormonaJ blockade (ONB) on one-year mortality among high-risk patients groups with CHE Methods: 501 consecutive pts with NYHA II IV class referred to our Department due to CHF were enrolled (mean age 694-11,316 male). We defined ONB as use of LBA and ACE-I in pts with NYHA II or LBA, ACE-I and spironolactone in pts with NYHA III-IV. Subgroup analyses were conducted for pts who were either elderly (>65 years)-gr.A (319 pts), had type 2 diabetes mellitus-gr.B (129 pts), low hemoglobine level ( 1.4 mg/dl)-gr.F (142 pts). Results: In groups A-F, respectively 45%, 47%, 39%, 36%, 44% and 31% of pts received ONB. One-year mortality in pts receiving optimal therapy was significantly lower in compare to pts with non-optimaJ therapy: gr.A: 13% vs. 45% (p<0.001), gr.B: 15% vs. 40% (p<0.005), gr.C: 13% vs. 53% (p<0.001), gr.D: 19% vs. 60% (p<0.001), gr.E: 21% vs. 44% (p<0.01), gr.F: 30% vs. 50% (p<0.05). Cox multivariate analysis showed that ONB independently reduced one-year mortality in each group (Table 1).