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Background: Acute kidney injury patients on continuous renal replacement therapy are subjected to alterations in metabolism, which in turn are associated with worse clinical outcome and mortality. The aim of this study is to determine which metabolism indicators can be used as independent predictors of 30 days intensive care unit (ICU) mortality., Methods: This was a prospective observational study on critical care patients on renal replacement therapy. Integrated approach of metabolism evaluation was used, combining the energy expenditure measured by indirect calorimetry, bioelectrical impedance provided fat free mass index (FFMI), amino acid and glucose concentrations. ICU mortality was defined as all cause 30 days mortality. Regression analysis was conducted to determine the conventional and metabolism associated predictors of mortality., Results: The study was conducted between the 2021 March and 2022 October. 60 high mortality risk patients (APACHE II of 22.98 ± 7.87, 97% on vasopressors, 100% on mechanical ventilation) were included during the period of the study. The rate of 30 days ICU mortality was 50% (n = 30). Differences across survivors and non-survivors in metabolic predictors were noted in energy expenditure (kcal/kg/day) (19.79 ± 5.55 vs 10.04 ± 3.97 p = 0.013), amino acid concentrations (mmol/L) (2.40 ± 1.06 vs 1.87 ± 0.90 p = 0.040) and glucose concentrations (mmol/L) (7.89 ± 1.90 vs 10.04 ± 3.97 p = 0.010). No differences were noted in FFMI (23.38 ± 4.25 vs 21.95 ± 3.08 p = 0.158). In the final linear regression analysis model, lower energy expenditure (exp(B) = 0.852 CI95%: 0.741-0.979 p = 0.024) and higher glucose (exp(B) = 1.360 CI95%: 1.013-1.824 p = 0.041) remained as independent predictors of the higher mortality., Conclusion: The results of the study imply strong association between the metabolic alterations and ICU outcome. Our findings suggest that lower systemic amino acid concentration, lower energy expenditure and higher systemic glucose concentration are predictive of 30 days ICU mortality., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The pathological mechanisms following aneurysmal subarachnoid hemorrhage (SAH) are poorly understood. Limited clinical evidence exists on the association between cerebrospinal fluid (CSF) volume and the risk of delayed cerebral ischemia (DCI) or cerebral vasospasm (CV). In this study, we raised the hypothesis that the amount of CSF or its ratio to hemorrhage blood volume, as determined from non-contrast Computed Tomography (NCCT) images taken on admission, could be a significant predictor for CV and DCI., Methods: The pilot study included a retrospective analysis of NCCT scans of 49 SAH patients taken shortly after an aneurysm rupture (33 males, 16 females, mean age 56.4 ± 15 years). The SynthStrip and Slicer3D software tools were used to extract radiological factors - CSF, brain, and hemorrhage volumes from the NCCT images. The "pure" CSF volume (V CSF ) was estimated in the range of [-15, 15] Hounsfield units (HU)., Results: V CSF was negatively associated with the risk of CV occurrence (p = 0.0049) and DCI (p = 0.0069), but was not associated with patients' outcomes. The hemorrhage volume (V SAH ) was positively associated with an unfavorable outcome (p = 0.0032) but was not associated with CV/DCI. The ratio V SAH /V CSF was positively associated with, both, DCI (p = 0.031) and unfavorable outcome (p = 0.002). The CSF volume normalized by the brain volume showed the highest characteristics for DCI prediction (AUC = 0.791, sensitivity = 0.80, specificity = 0.812) and CV prediction (AUC = 0.769, sensitivity = 0.812, specificity = 0.70)., Conclusion: It was demonstrated that "pure" CSF volume retrieved from the initial NCCT images of SAH patients (including CV, Non-CV, DCI, Non-DCI groups) is a more significant predictor of DCI and CV compared to other routinely used radiological biomarkers. V CSF could be used to predict clinical course as well as to personalize the management of SAH patients. Larger multicenter clinical trials should be performed to test the added value of the proposed methodology., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Subarachnoid hemorrhage (SAH) patients with cerebral autoregulation (CA) impairment at an early post-SAH period are at high risk of unfavorable outcomes due to delayed cerebral ischemia (DCI) or other complications. Limited evidence exists for an association between early-stage CA impairments and SAH patient outcomes. The objective of this prospective study was to explore associations between CA impairments detected in early post-SAH snapshot examinations and patient outcomes., Methods: The pilot observational study included 29 SAH patients whose CA status was estimated 2-3 days after spontaneous aneurysm rupture and a control group of 15 healthy volunteers for comparison. Inflatable leg recovery boots (reboots.com, Germany) were used for the safe controlled generation of arterial blood pressure (ABP) changes necessary for reliable CA examination. At least 5 inflation‒deflation cycles of leg recovery boots with a 2-3 min period were used during examinations. CA status was assessed according to the delay time (∆T CBFV ) measured between ABP(t) and cerebral blood flow velocity (CBFV(t)) signals during artificially induced ABP changes at boot deflation cycle. CBFV was measured in middle cerebral artery by using transcranial Doppler device., Results: Statistically significant differences in ∆T CBFV were found between SAH patients with unfavorable outcomes (∆T CBFV = 1.37 ± 1.23 s) and those with favorable outcomes (∆T CBFV = 2.86 ± 0.99 s) (p < 0.001). Early assessment of baroreflex sensitivity (BRS) during the deflation cycle showed statistically significant differences between the DCI and non-DCI patient groups (p = 0.039)., Conclusions: A relatively small delay of ∆T CBFV <1.6 s between CBFV(t) and ABP(t) waves could be an early warning sign associated with unfavorable outcomes in SAH patients. The BRS during boot deflation can be used as a biomarker for the prediction of DCI., Trial Registration: ClinicalTrials.gov Identifier: NCT06028906. Registered 31 August 2023 - Retrospectively registered, https://www., Clinicaltrials: gov/study/NCT06028906 ., (© 2024. The Author(s).)

Background and objectives: Amino acid (AA) loss is a prevalent unwanted effect of continuous renal replacement therapy (CRRT) in critical care patients, determined both by the machine set-up and individual characteristics. The aim of this study was to evaluate the bioelectrical impedance analysis-derived fat-free mass index (FFMI) effect on amino acid loss. Materials and methods: This was a prospective, observational, single sample study of critical care patients upon initiation of CRRT. AA loss during a 24 h period was estimated. Conventional determinants of AA loss (type and dose of CRRT, concentration of AA) and FFMI were entered into the multivariate regression analysis to determine the individual predictive value. Results : Fifty-two patients were included in the study. The average age was 66.06 ± 13.60 years; most patients had a high mortality risk with APAHCE II values of 22.92 ± 8.15 and SOFA values of 12.11 ± 3.60. Mean AA loss in 24 h was 14.73 ± 9.83 g. There was a significant correlation between the lost AA and FFMI (R = 0.445, B = 0.445 CI95%: 0.541-1.793 p = 0.02). Multivariate regression analysis revealed the independent predictors of lost AA to be the systemic concentration of AA (B = 6.99 95% CI:4.96-9.04 p = 0.001), dose of CRRT (B = 0.48 95% CI:0.27-0.70 p < 0.001) and FFMI (B = 0.91 95% CI:0.42-1.41 p < 0.001). The type of CRRT was eliminated in the final model due to co-linearity with the dose of CRRT. Conclusions: A substantial amount of AA is lost during CRRT. The amount lost is increased by the conventional factors as well as by higher FFMI. Insights from our study highlight the FFMI as a novel research object during CRRT, both when prescribing the dosage and evaluating the nutritional support needed.

Background: SARS-CoV-2 viral infection is associated with a rapid and vigorous systemic inflammatory response syndrome. Soluble urokinase-type plasminogen activator receptor (suPAR) is a novel biomarker, both indicative of inflammation and propagating it. Hemoadsorption has been proposed as a potential therapy in COVID-19 patients, therefore the aim of this study is to determine suPAR kinetics during hemoadsoprtion., Methods: This was a prospective observational study of critical COVID-19 patients, enrolled when hemoperfusion therapy was initiated. Hemoadsorber was integrated into the continuous renal replacement therapy circuit. The first series of suPAR measurements was performed 10 minutes after the start of the session, sampling both incoming and outgoing lines of the adsorber. A second series of the measurements was performed beforefinishing the session with the same adsorber. Statistical significance level was set < 0.05., Results: This study included 18 patients. In the beginning of the session the fraction of suPAR cleared across the adsorber was 29.5% [16-41], and in the end of the session it decreased to 7.2% [4-22], 4 times lower, p = 0.003. The median length of session was 21 hours, with minimal duration of 16 hours and maximal duration of 24 hours. The median suPAR before the procedure was 8.71 [7.18-10.78] and after the session was 7.35 [6.53-11.28] ng/ml. There was no statistically significant difference in suPAR concentrations before and after the session (p = 0.831)., Conclusions: This study concluded that in the beginning of the hemoadsorption procedure significant amount of suPAR is removed from the circulation. However, in the end of the procedure there is a substantial drop in adsorbed capacity. Furthermore, despite a substantial amount of suPAR cleared there is no significant difference in systemic suPAR concentrations before and after the hemoadsorption procedure., (© 2022. The Author(s).)

Background: As the COVID-19 pandemic continues, the number of patients admitted to the intensive care unit (ICU) is still increasing. The aim of our article is to estimate which of the conventional ICU mortality risk scores is the most accurate at predicting mortality in COVID-19 patients and to determine how these scores can be used in combination with the 4C Mortality Score., Methods: This was a retrospective study of critically ill COVID-19 patients treated in tertiary reference COVID-19 hospitals during the year 2020. The 4C Mortality Score was calculated upon admission to the hospital. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores were calculated upon admission to the ICU. Patients were divided into two groups: ICU survivors and ICU non-survivors., Results: A total of 249 patients were included in the study, of which 63.1% were male. The average age of all patients was 61.32 ± 13.3 years. The all-cause ICU mortality ratio was 41.4% (n = 103). To determine the accuracy of the ICU mortality risk scores a ROC-AUC analysis was performed. The most accurate scale was the APACHE II, with an AUC value of 0.772 (95% CI 0.714-0.830; p < 0.001). All of the ICU risk scores and 4C Mortality Score were significant mortality predictors in the univariate regression analysis. The multivariate regression analysis was completed to elucidate which of the scores can be used in combination with the independent predictive value. In the final model, the APACHE II and 4C Mortality Score prevailed. For each point increase in the APACHE II, mortality risk increased by 1.155 (OR 1.155, 95% CI 1.085-1.229; p < 0.001), and for each point increase in the 4C Mortality Score, mortality risk increased by 1.191 (OR 1.191, 95% CI 1.086-1.306; p < 0.001), demonstrating the best overall calibration of the model., Conclusions: The study demonstrated that the APACHE II had the best discrimination of mortality in ICU patients. Both the APACHE II and 4C Mortality Score independently predict mortality risk and can be used concomitantly., (© 2021. The Author(s).)

Background: Patients undergoing cardiac surgery have a pronounced immune response that leads to a reduction in cellular immunity. Immune-modulating nutritional supplements are considered to be beneficial for patients undergoing major surgery. However, due to the lack of studies in the cardiac surgery population, the effect of immunonutrition remains unclear in this patient group., Objective: Our purpose was to research the efficacy of early postoperative enteral immunonutrition on T-lymphocyte count in the cardiac surgery population., Methods: This was a randomised control study of low operative risk adult patients, who underwent elective cardiac surgery. These patients were randomised into immunonutrition and control groups. The immunonutrition group was supplemented with immune nutrients for five postoperative days. The counts of T-lymphocytes, as well as the counts for the CD4+ and CD8+ cell subpopulations were determined on the day of surgery and on the sixth postoperative day., Results: Fifty-five patients were enrolled in the study, the mean age was 69.7 ± 6.3 years, 28 (50.9%) of them were males, the median operative risk was 1.75%. Twenty-seven (49.1%) were randomised into the immunonutrition group. The control and the immunonutrition groups were similar before the intervention. The counts of the CD3+ T cells and CD4+ T cells on the sixth postoperative day were significantly higher in the immunonutrition group compared to the control group with 1.42 ± 0.49 vs. 1.12 ± 0.56 (∗10 9 /l), p = 0.035 and 1.02 ± 0.36 vs. 0.80 ± 0.43 (∗10 9 /l), p = 0.048, respectively. Regression analysis was performed to determine the efficacy of the immunonutrition on the counts of the CD3+ and CD4+ T cells; CD3+ T and CD4+ T cell counts were increased to 0.264 (∗10 9 /l), p = 0.039 and 0.232 (∗10 9 /l), p = 0.021, respectively., Conclusions: Early postoperative immunonutrition increases the count of the CD3+ and CD4+ T cells in cardiac surgical patients. Clinical trials identifier number: NCT04047095., Competing Interests: Conflicts of interest The authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Objective: To determine whether bioelectrical impedance-derived phase angle (PA) can be a predictor of red blood cell (RBC) transfusion in patients undergoing cardiac surgery., Design: An observational retrospective study of prospectively collected data., Setting: Single center, tertiary referral university hospital., Participants: The study sample comprised 642 adult patients undergoing elective cardiac surgery., Interventions: Patient demographic and clinical variables were collected. The body composition of the patients was evaluated by bioelectrical impedance analysis (BIA) the day prior to surgery. The rates of postoperative RBC transfusion were recorded., Measurements and Main Results: Among the 642 patients (67.8% men, median age of 66 [range 59-73]) included in the present study, 210 (32.7%) received at least 1 RBC unit postoperatively. Hypertension, preoperative stroke, renal failure, preoperative hemoglobin and hematocrit values, BIA-derived PA, aortic crossclamp time, and cardiopulmonary bypass (CPB) time were associated with the risk of RBC transfusion in the univariate analysis, and were included in the final multivariate regression model. Preoperative stroke (odds ratio [OR] 0.394; 95% confidence interval [CI]: 0.183-0.848; p = 0.017), preoperative hemoglobin values (OR 0.943; 95% CI: 0.928-0.960; p < 0.001), PA <15th percentile (OR 2.326; 95% CI: 1.351-4.000; p = 0.002), and CPB time (OR 1.013; 95% CI: 1.008-1.018; p < 0.001) were identified as independent predictors of RBC transfusion., Conclusion: Several factors were identified to be associated significantly with postoperative RBC transfusion in patients undergoing cardiac surgery. Among the conventional predictors, the value of the BIA-derived PA was indicated as a potent prognostic tool., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: We report a case of an adult patient with human immunodeficiency virus (HIV), acute respiratory distress syndrome (ARDS) and ventilator associated pneumonia (VAP) caused by multidrug resistant (MDR) bacteria that was successfully managed with veno-venous extracorporeal membrane oxygenation (ECMO)., Case Report: A 25 year old male with no significant past medical history had been admitted to a local hospital due to dyspnea and fever. His pulmonary function subsequently failed necessitating mechanical ventilation (MV) and introduction of ECMO support. The patient was transported for 300 km by road on ECMO to a tertiary medical center. The diagnosis of ARDS, HIV infection and MDR bacterial and fungal VAP was made. Patient was successfully treated with antiretroviral therapy (ART), anti-infective agents and 58 days of veno-venous ECMO support, with complete resolution of the respiratory symptoms., Conclusion: HIV infected patients with ARDS and MDR bacterial VAP whose HIV replication is controlled by ART could be successfully managed with ECMO.

Introduction: One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion., Aim: We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method., Material and Methods: We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy., Results: There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days., Conclusions: Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Context: Hypertriglyceridemia is a well known phenomenon of pregnancy occurring due to physiologic changes in sex hormone levels. Occasionally, it could lead to development of acute pancreatitis. Gestational hypertriglyceridemia-induced acute pancreatitis occurs in pregnant women usually with preexisting abnormalities of the lipid metabolism and is associated with additional diagnostic and therapeutic challenges related to hypertriglyceridemia and pregnancy., Case Report: We present a case of the hypertriglyceridemia-induced acute pancreatitis in pregnant woman with no previous history of lipid abnormality and pregnancy as the only known triggering factor for hypertriglyceridemia., Conclusions: Hypertriglyceridemia-induced acute pancreatitis is a rare complication of pregnancy; however, it should be suspected in all pregnant patients admitted for nonobsteric abdominal pain.

Enterobius vermicularis is one of the most common intestinal parasites found in humans. They commonly infest the terminal ileum and large intestine, and are usually considered an innocuous parasite that can be easily eradicated with proper treatment. However, extraintestinal migration of worms, although very rare, may lead to severe health disorders or even death. This article, reports the first fatal case of ectopic enterobiasis known to the authors, which developed in an adult patient with E. vermicularis infection, causing perforation of the large intestine and generalized bacterial peritonitis. Despite emergency laparotomy, the patient died from septic shock on the day after surgery. During pathological examination, worms were found not only in the large intestine, but also in the renal parenchyma; worm eggs were found deposited in the lungs as well.

Background: Liver transplantation has become the treatment of choice for chronic and acute end-stage liver failure as well as for selected cases of malignancies and metabolic disorders. We report our first experience of the orthotopic liver transplantation., Material/methods: Between 2005 and 2008 16 cadaveric orthotopic liver transplantations in 16 adults (12 males, 4 females, mean age 44 years) were performed. Main indications for orthotopic liver transplantation were cholestatic liver disease (31%), viral-induced cirrhosis (25%), alcoholic liver disease (19%), hepatocellular carcinoma associated with hepatitis virus infection (13%), autoimmune cirrhosis (6%), cryptogenic acute liver failure (6%). Mean follow-up was 15 month (range: 4 days - 43 month)., Results: Intraabdominal haemorrhage was observed in 6 patients (37.5%). Vascular complications were observed in 3 patients (18.75%). Biliary complication were observed in 3 patients (18.75%). Overall 1 year patient survival was 87,5%. Four (25%) patients died during follow-up. All patients died because of sepsis and multiorgan system failure., Conclusions: Our first results showed that secret of successful liver transplantation is perfect interdisciplinary team approach, including selection of the recipient and timing of transplantation, the operative procedure itself, prevention and treatment of complications, the perioperative anaesthesiological and intensive-care management, and careful follow up after transplantation.

Objective: The objectives of this study were to determine the incidence of intra-abdominal hypertension in patients after major abdominal surgery and to evaluate the correlation of intra-abdominal pressure with fluid balance and systemic inflammatory response syndrome., Material and Methods: This is a prospective observational study. Patients, admitted to intensive care unit after major abdominal surgery, were included into the study. Intra-abdominal pressure was measured via a urinary bladder catheter twice daily. Twenty-four-hour fluid balance and systemic inflammatory response syndrome criteria met by the patients were collected daily., Results: Seventy-seven patients were included into the study. Intra-abdominal hypertension was diagnosed in about 40% of the patients in the early postoperative period. The study showed a significant positive correlation between 24-hour fluid balance and daily changes in intra-abdominal pressure. A significant association was also seen between the number of positive systemic inflammatory response syndrome criteria and intra-abdominal pressure, and intra-abdominal pressure was significantly higher in patients with systemic inflammatory response syndrome. Besides, patients with intra-abdominal hypertension on the first postoperative day had longer length of stay in the intensive care unit., Conclusions: Intra-abdominal hypertension occurs commonly in patients after major abdominal surgery, and patients with positive 24-hour fluid balance and/or systemic inflammatory response syndrome are at risk of having higher intra-abdominal hypertension.

In clinical practice, intra-abdominal pressure is usually measured indirectly via the urinary bladder using Foley catheter. This technique is minimally invasive, safe, simple and accurate. Intra-abdominal hypertension is defined as an intra-abdominal pressure above 12 mmHg. Rapid progression of intra-abdominal hypertension will lead to abdominal compartment syndrome, which is defined as an intra-abdominal pressure greater than 20 mmHg with at least one organ failure. The incidence of intra-abdominal hypertension is variable and depends on the values used to define it and on the study population. However, the mortality rate of intra-abdominal hypertension and abdominal compartment syndrome is high. Increase in intra-abdominal pressure causes significant impairment of almost all organ systems. Even slight increase in intra-abdominal pressure has negative influence on the respiratory, cardiovascular, cerebral, gastrointestinal, hepatic, and renal functions. Intra-abdominal hypertension causes visceral organ hypoperfusion, intestinal ischemia and may also lead to bacterial translocation, release of cytokines and production of free oxygen radicals. All these factors may contribute to the development of multiple organ failure in the critically ill patients. Intravascular fluid replacement and abdominal decompression are the standards of treatment for abdominal compartment syndrome.