Increased IAP often coexists with sepsis in severely ill patients in the ICU, under mechanical ventilation and pharmaceutical support of the circulation with inotropes and vasoactive drugs. Both conditions have an unfavorable effect on the cardiovascular system. The purpose of this experimental study was to record the effect of increased intra-abdominal pressure on the cardiovascular system of pigs, with or without additional sepsis. Sixteen male pigs were randomly assigned in two groups A and B. In both groups, after induction to anesthesia and mechanical ventilation, the intra-abdominal pressure was increased to 25mmHg by helium insufflation in the peritoneal cavity, and that level of IAP was preserved until the end of the experiment. In Group A no other intervention apart from the increase in IAP was made, whereas in Group B, 60 minutes after the increase in IAP, 100μg/kg LPS were administered. Data were recorded after induction of anesthesia and initiation of mechanical ventilation (baseline measurement/measurement 0) and thereafter every 20 min after intra-abdominal pressure increase. The last measurement (measurement 9) was obtained immediately before release of pneumoperitoneum. Parameters measured or calculated included HR, BP(s,d,m), RVPs, PAP(s,d,m), PΑWP, CO, SV, SVR, PVR, SvO2, ETCO2. HR increased statistically significantly only in Group B, 60 minutes after the administration of LPS. BP (s, d, m) presented a significant change only in Group B, an initial increase immediately after LPS administration, followed by a decrease. CVP, RVPs and PAP (s, d, m) increased in both groups after IAP increase, whereas they presented an additional increase in Group B, after LPS administration. PΑWP changed only in Group B, after LPS administration. CO and SV were dramatically reduced in Group B, immediately after LPS administration, but gradually recovered their initial values until the end of the experiment. SVR changed only in Group B. They increased after LPS administration and then they gradually decreased. PVR increased dramatically after LPS administration and, despite gradual decrease they remained at high values until the end of the experiment. SvO2 decreased in Group B after LPS administration but gradually recovered its initial values. At the conditions of this particular experiment, the increase in intra-abdominal pressure was well tolerated by the laboratory animals. On the contrary, sepsis induction by LPS administration had an unfavorable effect on the cardiovascular system.
Continue readingAdequate adrenocortical function is essential to survive critical illness. The goal of this study was to determine whether eosinophilia could serve as a useful and early marker of adrenal insufficiency in critically ill patients with severe septic shock. During a 1-year period, we prospectively studied 294 ICU patients.16 patients (5.4% of ICU admissions) with eosinophilia more than 3% of the white blood cell count and septic shock unresponsive to adequate fluid and vasopressor therapy, were included. A high dose (250 mcg i.v) corticotropin stimulation test was performed. Eosinophilia (>3%) was diagnosed in 16 patients with vasopressor-unresponsive septic shock. Eosinophilia was present 1.9±0.9d (range 8-96h) before the onset of septic shock. 11/16 patients failed to respond to corticotropin stimulation test above the critical level of 9 mcg/dL rise and 2/16 had baseline cortisol concentration <10 mcg/dL. Baseline cortisol level, maximal cortisol increase post-corticotropin administration and Eosinophils count (%) were higher in survivors (p≤0.05). A hydrocortisone infusion (300mg/d) treatment resulted in haemodynamic improvement in 12 of 16 patients (75%). The 28-day mortality (following the onset of septic shock) was 43.7%. Relative eosinophilia may be considered as a useful and early bioassay for adrenocortical function assessment in critically ill patients with septic shock and assumed adrenocortical depression.
Continue readingThere are various formulas and algorithms for the prediction of body weight and appropriate ETT size, in pediatric patients. Body Weight estimation is of paramount importance in pediatrics, especially in emergencies. Predicting the appropriate size of the endotracheal tube saves time, money and reduces complications. The goal of this study was to evaluate the validity of two commonly used formulas for predicting the body weight and the size of the appropriate endotracheal tube, both based on age.353 consecutive pediatric surgical patients aged 2 to 12 years, who required general anesthesia and oral endotracheal intubation were included in this study. Patients were stratified according to their age in two groups: group 2-5 (79 children, 2 to 5 years) and group 6-12 (274 children, 6 to 12 years). At the end of surgery an anesthesiologist, who was not involved in the perioperative treatment, recorded the demographic data and also the size and type of the endotracheal tube used. The prediction of Body Weight (BW) was made according to the following formula: 2-5 y.o.: Weight (kg) = (2 x age in years) + 8 and 6-12 y.o.: Weight (kg) = (3 x age in years) + 7. The formula for calculating the size (size= internal diameter=I.D.) of the endotracheal tube (ETT) was: I.D. for cuffed ETT (mm) = (age / 4) + 3.5 and I.D. for uncuffed ETT (mm) = (age / 4) + 4. For all statistical tests p value <0.05 was considered as statistically significant. In all patients as sum and in both age groups, the predicted body weight was significantly (p<0.05) lower than the actual (measured) weight. In group 2-5y.o, 74.7% of patients received cuffed ETT In group 6-12y.o. 100% of patients received cuffed ETT. In group 2-5 y.o, all patients showed a significantly (p<0.05) lower predicted internal diameter of the ETT, either cuffed or uncuffed, compared to ETT ultimately used. In group 6 -12y.o, there was no statistically significant difference between the predicted and the actually used ETT size. The prediction of body weight in children, by the use of the particular formula, led to underestimation. In children aged 2 to 5 years, the application of the inner diameter calculation of the ETT formula also underestimated the appropriate ETT size. It seems that the traditional age-based formulas often fail to predict the correct ETT size in smaller children which probably does not seem to apply to older children.
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The health system’s response characteristics to any refugee crises have special characteristics. Optimal and flexible use of health services is essential in order to meet the needs that arise. Greece has been at the center of such crisis in the last 3 years. The purpose of this study is to record the emergency refugees' transports carried out by the National Center of Emergency Care (“ EKAB”) of Thessaloniki during a 6 months period. In a retrospective study, selected data for the use of emergency care service by the refugees’ camps around Thessaloniki were recorded and analyzed. Parameters included the date, time and location of the incident, patient demographics, callers’ status and incident type. Data on refugee flow in Greece was also included for the same period. Data from 1916 records were analyzed, the majority of which were ages up to 45 years (> 70%). Time distribution of the data displayed increased transport during the first 3 months of the study, followed by a steady decrease. Most of the transports were carried out during the last 3 days of the week. In comparison with the general population, high incident of pediatric cases were recorded. Trauma cases were also high, (35%) - with equally high rates of crime-related injuries. Finally, many ambulance transports were carried out due to delivery or early pregnancy-related problems. Young people and children are the most frequently users of ambulances’ transport from refugee hosting camps. However, due to the complexity of the problem and the dynamic nature of the camps’ population composition, more studies are needed in order to properly evaluate the use of each sector of the health system by refugees.
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In cardiac surgery, head-down and head-up positions are used to control cardiac filling pressure and for cardiac exposure. Even though benefits of head positioning are not clear, they can also bring some risks. Understanding physiological consequences of positioning can help avoiding serious adverse events and complications. In this prospective study we investigated the effect of head-down and head-up position upon systemic and cerebral haemodynamics and cerebral oxygenation and their correlation with Bispectral Index (BIS) in CABG patients under general anesthesia before surgical incision. Thirty patients were enrolled in to the study. After induction and before surgical incision blood pressure, heart rate, central venous pressure, cardiac output, stroke volume variation, BIS, cerebral oxygen saturation and middle cerebral artery blood flow rate values of the study patients were measured at neutral, head-down and head-up positions. The significance of the difference in terms of the means between the positions was studied with the repeated measures analysis of variance, while the significance of the difference in terms of the mean values was analyzed with Friedman test. Statistically significant increase were recorded in blood pressure, cardiac output, central venous pressure, cerebral blood flow rate and BIS values in the head-down position. The head-up position was associated with decrease in cardiac output. We demonstrated that both positions are safe for cerebral haemodynamics and oxygenation in ischemic heart patients. We showed that the short term head-down position can improve cardiac function, probably due to increased preload in ischemic heart patients with normal ejection fraction; however, the head-up position can be detrimental for systemic haemodynamic even for a short period.
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Patient care in Intensive Care Units is characterized by high demanding tasks, which leads in daily high workload. The aim of the study is to evaluate the effect of patient’s sedation level to workload for the certain task. It also examines whether workload lowers over time, as an effect of the experience gained by the repetition of the task. NASA- TLX tool was used as workload assessments method during a complex monitoring task in an adult Intensive Care Unit environment. The latter included monitoring and recording of skin conductance variability, noise level, hemodynamic and respiratory parameters were monitored during 4 hour routine in two groups of patients. The group was defined by the sedation level (Ramsay sedation score); otherwise no major differences were spotted in their characteristics. Both raw and weighted data of the NASA-TLX tool were included in the analysis, which was performed with MS Excel 2007 (Microsoft Co, USA) and Rstudio® IDE v.0.99.903 (Rstudio Inc, Boston, MA, USA). Patients’ sedation level did not affect NASA-TLX measured workload. The former was valid both for raw values and weighted data of the subscales of the NASA-TLX tool. In the second part of the analysis where the raw values were treated as time series data, it was shown that some subscales (Ment, Phys) had a tendency towards lower values, others (e.g. Temp, Ef) had a relative stability and others (Per) increased over time. The total workload (OW) did not seem to lower over time. While the patient’s sedation level does not affect workload of the specific task, several subscales of the NASA-TLX index do reveal a tendency over time; a fact that may be used as learning curve/ experience assessment for a given task. However, further studies are needed in order to define its future utility.
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Prehospital emergency medical services (PEMS) are becoming more and more sophisticated as more point-of–care advanced medical technology is available in the field. Yet, the literature around the subject is limited, as data come mainly from Northern Europe, USA, Canada and New Zealand. The aim of this analysiswas to describe time trends of PEMS activity in a region of northern Greece.Use of data retrospectively collected for PEMS usage, in the regional unit of Thessaloniki, Northern Greece from 2006 to 2015. The area of interest represents a little more than 10% of the total population of Greece.Total utilization of PEMS shows an overall l4.03% decrease over the decade; yet with an increase in the 2 last years.The mean rate of use was 69/1000 inhabitants for ambulance services and 1.5/1000 for medical interventions (MICU).
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The interaction between increased Intra Abdominal Pressure (IAP) and Intrathoracic Pressure under different Positive End Expiratory Pressure (PEEP) levels is intriguing, since these two conditions coexist frequently in several clinical settings. The aim of our study was to investigate the interaction between different PEEP levels and increased IAP during laparoscopic cholecystectomy. In fifty two patients, who underwent scheduled laparoscopic cholecystectomy, cardiovascular parameters were determined by an Oesophageal Doppler Monitor device during two different time periods, before and after pneumoperitoneum, and under five conditions: (i) PEEP 0 cmH2O (ii) PEEP 5cm H2O (iii) PEEP 10cm H2O (iv) PEEP 15cm H2O and (v) in the absence of PEEP or ventilation. Cardiac output and stroke volume showed a statistically significant decrease compared to the baseline value after the application of different PEEP levels, when there was no pneumoperitoneum (p<0.05). However, both parameters increased, when PEEP and pneumoperitoneum were applied together (p<0.001). Corrected flow time, peak flow velocity in the descending thoracic aorta and mean acceleration showed similar alterations but not at all PEEP levels. Finally, αt the no PEEP or ventilation phase, the negative effects of increased IAP on the cardiocirculatory function were predominant. According to these results, application of PEEP seems to counterbalance the negative hemodynamic effects of increased IAP. Moreover, it could also be concluded that ‘ideal’ PEEP level might be the one that borders the IAP level, since the best cardiac output and stroke volume values were reported at that point.
Continue readingDuring recent years the application of non invasive ventilation (NIV) has emerged as a central component of respiratory failure management, acute and chronic. Although the use of NIV in acute respiratory failure was initially meant to be given in critical care units, it is nowadays natural to provide it in other settings as well, provided that there are the necessary resources and expertise. NIV represents a viable alternative to endotracheal ventilation and despite most data refer to patients with chronic obstructive pulmonary disease; its indications are continuously expanding to cover more clinical scenarios. Randomized controlled studies are needed in order to provide sound evidence regarding optimal patient-ventilator interface, NIV duration and ventilation parameters in thoracic surgery patients.
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This research was designed to determine the appropriateness and applicability of the Patient Bill of Rights from the viewpoint of nurses in Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012. This is a descriptive-analytical study. Out of 440 questionnaires delivered to the nurses, 294 were completed. The data collection tool was a questionnaire related to the five domains of the Patient Bill of Rights including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system. The mean scores for appropriateness (350.16±7.23) and applicability (282.57±54.22) of the Patient Bill of Rights were high. Shortage of work force, nurses and patients’ unawareness of the major barriers of application, provision of necessities for internalization, establishment of the committee of the Patient Bill of Rights, and paying attention to nurses’ rights were the solutions proposed. Enhancing stakeholder’ s awareness and providing necessities by managers can help in the operationalization of the Bill.
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