Mariusz Piechota

Natriuretic peptides in cardiovascular diseases

The natriuretic peptide family comprises atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), C-type natriuretic peptide (CNP), dendroaspis natriuretic peptide (DNP), and urodilatin. The activities of natriuretic peptides and endothelins are strictly associated with each other. ANP and BNP inhibit endothelin-1 (ET-1) production. ET-1 stimulates natriuretic peptide synthesis. All natriuretic peptides are synthesized from polypeptide precursors. Changes in natriuretic peptides and endothelin release were observed in many cardiovascular diseases: e.g. chronic heart failure, left ventricular dysfunction and coronary artery disease.

N-terminal brain natriuretic propeptide levels correlate with procalcitonin and C-reactive protein levels in septic patients

The aim of this study was to find the relationship between N-terminal brain natriuretic propeptide (NT-proBNP), procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations in septic patients. This was a prospective study, performed at Medical University Hospital No. 5 in łódź. Twenty patients with sepsis and severe sepsis were included in the study. N-terminal brain natriuretic propeptide, procalcitonin and C-reactive protein concentrations, and survival were evaluated. In the whole studied group (128 measurements), the mean NT-proBNP, procalcitonin and C-reactive protein concentrations were, respectively: 140.80±84.65 pg/ml, 22.32±97.41 ng/ml, 128.51±79.05 mg/l. The correlations for the NT-proBNP level and procalcitonin and C-reactive protein levels were 0.3273 (p<0.001) and 0.4134 (p<0.001), respectively. NT-proBNP levels correlate with PCT and CRP levels in septic patients. In the survivor subgroup, the mean NT-proBNP plasma concentrations were significantly lower than in the non-survivor subgroup.

Anaesthetic management of a patient with myasthenia gravis for abdominal surgery using sugammadex.

We report a case of a patient with tumor of the caecum with coexistent myasthenia gravis (a form according to Osserman II A), requiring general anesthesia for abdominal surgery. To reverse the neuromuscular block induced by vecuronium was used sugammadex.

Rationale of statin therapy in septic patients

Statins are well-established and effective drugs in the treatment of hyperlipidemias. However the effects of statins extend beyond lipid-lowering. The pleiotropic effects of statins have been shown to modify inflammatory cell signaling of the immune response to infection. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. It was postulated that statins may be candidates for the treatment of sepsis. Recent animal and human data suggest that statin therapy might be beneficial in patients before the onset of sepsis or in its initial period, but should be used with care when patients are diagnosed with severe sepsis or septic shock. Some analyses also provide evidence for statins as an adjuvant therapy in sepsis. Because of the divergent results of studies, the potential benefit needs to be validated in randomized, controlled trials. In this review, we describe current evidence on the use of statins in the prevention and treatment of sepsis.

Hepatic encephalopathy in the course of alcoholic liver disease — treatment options in the intensive care unit

Hepatic encephalopathy occurs as a complication of alcoholic liver disease may require methods of dialysis available in intensive care units. There is described the case of a 27-year-old patient with jaundice and hepatic encephalopathy with long history of alcohol dependence and substance abuse. The patient was successfully treated using liver dialysis method (Prometheus® system). Basing on this case it is possible to conclude that use of dialysis liver with Prometheus® may be beneficial in patients with severe course of alcoholic liver disease.

Guidelines regarding the ineffective maintenance of organ functions (futile therapy) in ICU patients incapable of giving informed statements of will

1National Consultant in intensive therapy, Chair and 1st Department of Anaesthesiology and Intensive Therapy, Wrocław Medical University, Poland 2Department of Medical Law, Chair of Forensic Medicine, Wrocław Medical University, Poland 3Chair and 2nd Department of Anaesthesiology and Intensive Therapy, Wrocław Medical University, Poland 4National Consultant in anaesthesiology and intensive therapy, Chair and Department of Anaesthesiology and Intensive Therapy, Collegium Medicum, Nicolaus Copernicus University (NCU) in Toruń, Poland 5Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Łódz, Poland 6Department of Respiratory Physiopathology and Home Ventilation, Chair of Anaesthesiology and Intensive Therapy, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland

An Evaluation of the Usefulness of Extracorporeal Liver Support Techniques in Patients Hospitalized in the ICU for Severe Liver Dysfunction Secondary to Alcoholic Liver Disease

Background The mortality rate in patients with severe liver dysfunction secondary to alcoholic liver disease (ALD) who do not respond to the standard treatment is exceptionally high. Objectives The main aim of this study was to evaluate the usefulness of applying extracorporeal liver support techniques to treat this group of patients. Patients and Methods The data from 23 hospital admissions of 21 patients with ALD who were admitted to the department of anesthesiology and intensive therapy (A&IT) at the Dr Wł. Biegański Regional Specialist Hospital in Łódź between March 2013 and July 2015 were retrospectively analyzed. Results A total of 111 liver dialysis procedures were performed during the 23 hospitalizations, including 13 dialyses using fractionated plasma separation and adsorption (FPSA) with the Prometheus® system, and 98 procedures using the single pass albumin dialysis (SPAD) system. Upon admission to the intensive care unit (ICU), the median (interquartile range [IQR]) Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE) II, and simplified acute physiology score (SAPS) II scores were 15 (14 - 15), 9 (7 - 13), 17 (14 - 24), and 32 (22 - 50), respectively. The ICU, 30-day, and three-month mortality rates were 43.48%, 39.13%, and 73.91%, respectively. As determined by the receiver operative characteristic (ROC) analysis for single-factor models, the significant predictors of death in the ICU included the patients’ SOFA, APACHE II, SAPS II, and model of end-stage liver disease modified by the united network for organ sharing (MELD UNOS Modification) scores; the duration of stay (in days) in the A&IT Department; and bile acid, creatinine and albumin levels upon ICU admission. The ROC analysis indicated the significant discriminating power of the SOFA, APACHE II, SAPS II, and MELD UNOS modification scores on the three-month mortality rate. Conclusions The application of extracorporeal liver support techniques in patients with severe liver dysfunction secondary to ALD appears justified in the subset of patients with MELD UNOS Modification scores of 18 - 30.

Liver Cell Carcinoma in Poland: Data Reported to the National Health Fundin the Years 2008-2012

Introduction: Liver cell carcinoma includes primary malignant liver neoplasms originating from epithelial cells. Liver cell carcinoma is one of the most common cancers and is the 3rd leading cause of cancer-related mortality worldwide. However, the epidemiology and the various available treatment options have not been sufficiently studied in Poland. The aim of the present study was to assess the frequency of use of various liver cell carcinoma treatments in Poland based on data reported by service providers to the National Health Fund in the years 2008-2012. Patients and methods: Data concerning patients with liver cell carcinoma were obtained by querying the National Health Fund databases. The data were collected from the databases using SQL tools and a filter in accordance with the accepted scope of ICD-10 diagnoses. The analysis was conducted using Excel and Statistica 10. The demographic data were collected from the Central Statistical Office’s website. Results: Data on the number of patients and the type of medical services available for patients with a diagnosis of liver cell carcinoma financed by NFZ in the years 2008-2012 are described. Conclusions: The health care system in Poland does not provide liver cell carcinoma patients with rapid access to required health care services, which decreases patient survival. Treatment of advanced stage liver cell carcinoma with Sorafenib, with public payer financing, represents a real and accessible alternative treatment option for this group of patients.

Predictive value of the APACHE II, SAPS II, SOFA and GCS scoring systems in patients with severe purulent bacterial meningitis.

BACKGROUND Scoring systems in critical care patients are essential for predicting of the patient outcome and evaluating the therapy. In this study, we determined the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) and Glasgow Coma Scale (GCS) scoring systems in the prediction of mortality in adult patients admitted to the intensive care unit (ICU) with severe purulent bacterial meningitis. METHODS We retrospectively analysed data from 98 adult patients with severe purulent bacterial meningitis who were admitted to the single ICU between March 2006 and September 2015. RESULTS Univariate logistic regression identified the following risk factors of death in patients with severe purulent bacterial meningitis: APACHE II, SAPS II, SOFA, and GCS scores, and the lengths of ICU stay and hospital stay. The independent risk factors of patient death in multivariate analysis were the SAPS II score, the length of ICU stay and the length of hospital stay. In the prediction of mortality according to the area under the curve, the SAPS II score had the highest accuracy followed by the APACHE II, GCS and SOFA scores. CONCLUSIONS For the prediction of mortality in a patient with severe purulent bacterial meningitis, SAPS II had the highest accuracy.

Is the unadjusted ICU mortality a good indicator of quality of ICU care

Dear Editor, We read with great interest the letter by Weigl et al. comparing ICU mortality in selected European countries. The authors reported a significantly higher mortality in Poland (42%) as compared to other countries (6.7–17.8%) [1]. They concluded that the results “could be useful for stimulating improvement of critical care services in Poland” [1]. While Weigl et al. should be commended for their effort to inform the readers about variability in ICU mortality across Europe, we are very concerned about the fact that they reported and interpreted unadjusted mortality rates. We do not question the presented ICU mortality rates in Poland and we concur with the authors’ statement that the rates are high; however, we want to point out why such a simplistic interpretation is unsatisfactory and scientifically incorrect. The problem with the report, in our opinion, is the fact that authors failed to present the severity of the patients’ condition at the time of ICU admission in each country. It is well documented that objectively assessed patient condition (for instance with the APACHE II scale) correlates with ICU mortality. Rowan et al. [2] demonstrated that mortality in patients with APACHE II score 15–19, 20–24, and 25–29 was 18.8% (17.1–20.5), 37.9% (35.5– 43.3), and 56.9% (53.6–60.2), respectively. Data form the Polish National Consultant shows that average APACHE II score at the time of ICU admission was 26 in 2015 (Table 1). It was significantly higher than in the Netherlands and Sweden, whose average ICU admission APACHE II scores were reported to be around 15 and not surprisingly these countries had lower ICU mortality (Table 1). Another important consideration completely ignored by Weigl et al. is the difference in the number of ICU beds available in each of the compared countries; for instance in Great Britain and Germany there were 3.3 and 24 ICU beds per 100,000 people, respectively (cf. 7.12 in Poland). It was shown that number of available ICU beds per capita correlates with mortality [5]. In our opinion, unadjusted mortality rates are impossible to meaningfully interpret and certainly can lead to erroneous conclusions, in particular when the patient severity mix is not taken into consideration [6]. It seems that use of standardized mortality ratio (SMR), which was approved by ESICM as one of nine quality and safety indicators in ICU care, would be a more meaningful way to compare mortality in different European countries [6]. Published SMR data from Poland and from any other European countries for that matter, except for Denmark, is scant. However, the SAPS III SMR available from a single center in Poland was 0.98 (0.74–1.28) and comparable to that in other European countries with lower unadjusted mortality (Table 1). Although we are not disputing the unadjusted mortality rates presented by Weigl et al., we respectfully disagree with their interpretation, suggesting that unadjusted mortality directly represents the quality of ICU care. We hope that in the future SMR will be widely reported in each country to allow more objective comparison of the quality of care delivered in different intensive care units across Europe.