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Objectives The aim of this study was to describe the patterns of antimicrobial resistance (AMR) of bacterial isolates causing hospital-acquired infections (HAIs) in the intensive care unit (ICU) of a tertiary hospital in Kazakhstan. Methods This was a retrospective analysis of AMR in the ICU of the National Research Center for Oncology and Transplantation (Astana, Kazakhstan) during the year 2015. Results During the study period, 546 patients were admitted to the ICU, of whom 135 (24.7%) developed at least one HAI. Most HAIs caused by Gram-positive bacteria were due to Enterococcus faecalis, which were resistant to aminoglycosides in >70% cases. Gram-negative bacteria were isolated in ca. 50% of cases, thus representing the greatest burden of HAIs. Very high resistance rates to ceftriaxone, cefotaxime and cefuroxime were observed. Moreover, Pseudomonas aeruginosa and Acinetobacter baumannii were resistant to carbapenems in Conclusion This study demonstrates the urgent need to implement more rational use of antimicrobials in Kazakhstan, which can be done only by establishing a proactive surveillance system along with an appropriate infection control programme.

This article reports the largest nosocomial outbreak of B. cepacia-related Hospital Acquired Infectios (HAIs) and the epidemiological investigations leading to identification of ultrasound gel as a direct means of infection transmission. Multiple environmental sampling was conducted to identify the source and route of infection. The samples were collected from all sources considered to be potential reservoirs of B. cepacia. Standard methods for pathogen isolation and antibiotic sensitivity testing were used. In all, 61 patients developed B. cepacia-related sepsis and this agent was isolated only from ultrasonography gel. All patients required the placement of a central venous line to receive the chemotherapy for the underlying hematologic disease. The hospital outbreak persisted after identification of the source of infection and it took more than four months to be completely eradicated after the first cases. B. cepacia is a serious threat for hospitalized patients needing invasive procedures, including the central line placement for chemotherapy, regardless of the need of any intensive care. Implementation of protocols for active surveillance of HAIs should also target this opportunistic agent and include periodic sterility control of commonly used medical materials, including ultrasonography gel and equipment.

Postoperative delirium (POD) is a condition characterized by cerebral dysfunction or failure and associated with high morbidity and mortality, prolonged intensive care unit and hospital stay, increased costs and long-term disability. The risk factors can be divided into three categories: preoperative, intraoperative, and postoperative. POD is underrecognized, underdiagnosed, and undertreated condition which can lead to potentially life-threatening conditions. Prevention and treatment of POD include adequate perioperative pain control, maintenance of optimal blood pressure, water-electrolyte balance, hypoglycemia, hyperglycemia, sleep hygiene. Despite POD has been extensively studied in various types of surgery, there is not enough evidence on POD in intracranial neurosurgery. Patients undergoing open craniotomy might be at particular risk because on top of the above-mentioned factors, they also can have a direct neurosurgical brain injury. Future research on the POD in neurosurgical patients after intracranial interventions is needed. A bibliographic search was performed in the MEDLINE and PubMed virtual library. The following descriptors were used: POD, neurosurgery, anesthesia and POD, postoperative pain management and POD, water and electrolyte imbalance and POD, neurochemistry of POD. We included in this review original and review articles in the English language. Majority of non-neurosurgical patients have multiple risk factors for POD (preoperative, intraoperative, and postoperative); patients undergoing intracranial neurosurgery might have additional risks associated with neurosurgical pathology (brain tumor, cerebral hemorrhage, and severe traumatic brain injury) as well as neurosurgery-induced brain injury can also appear to be a contributing factor.

Background Cancellation of scheduled cases on the day of surgery leads to waste of resources, financial burden, patient dissatisfaction, extended hospital stay, and unnecessary repetition of preoperative preparations. The purpose of this retrospective study was to analyze the causes of case cancellation in our institution so as to improve hospital quality control as well as perioperative risk management. Methods We conducted a retrospective analysis of all cancellations of scheduled elective surgical procedures. We analyzed all cases that were canceled after the patient had been delivered to the operating room (OR). The data about case cancellations was obtained from the Hospital Information System (HIS) of the National Research Oncology and Transplantation Center. Results The most common single reason for cancellation was preoperative hypertensive crisis (n=67; 80.7%), followed by heart rhythm disorders (n=6; 7.2%), incomplete preoperative patient evaluation (n=5; 6.1%), myocardial ischemia (n=4; 4.8%), and pneumonia (n=1; 1.2%). Most of the cancellations (76 out of 83; 92%) were considered to be potentially avoidable. Conclusions In conclusion, that the most common reasons for case cancellation were patient-related cardiovascular conditions (preoperative hypertensive crisis, dysrhythmia, myocardial ischemia). Improvement in preoperative assessment and management of the cardiovascular condition is needed to reduce scheduled case cancellation rate.

BACKGROUND Hemofiltration reduces blood levels of cytokines, glutamate, and other substances that increase the risk of stroke-associated neurodegeneration. This study aimed to assess the safety and efficacy of hemofiltration in acute ischemic stroke patients. METHODS A total of 37 patients (mean age 56 ± 16 years) who had an ischemic stroke within the previous 12 hours were randomized to receive hemofiltration for 36 hours (n = 19) or standard treatment (n = 18). The primary outcome of interest was the occurrence of adverse events during the 28-day period following the stroke symptom onset. The secondary outcome was to assess the efficacy of hemofiltration in acute ischemic stroke. RESULTS Eighteen patients who received hemofiltration and 17 patients who received standard care completed the study. There were no cases of sepsis or infection at the hemofiltration cannula site, nor other hemofiltration-related complications. There was one case of fatal hemorrhagic transformation in each of the two groups. We failed to find any favorable effects on NIHSS scores at 7 days. However, we observed 17 patients (94%) with systemic inflammatory response syndrome in the control group and only 13 (68%) in the hemofiltration group. CONCLUSION Hemofiltration appears to be safe in acute ischemic stroke patients, but we were unable to demonstrate its efficacy. However, for a definite conclusion on efficacy, a larger study with longer follow-up is required.

Glutamate toxicity plays a well-established role in secondary brain damage following acute and chronic brain insults. Previous studies have demonstrated the efficacy of hemodialysis and peritoneal dialysis in reducing blood glutamate levels. However, these methods are not viable options for hemodynamically unstable patients. Given more favorable hemodynamics, longer treatment, and less needed anticoagulation, we investigated whether hemofiltration could be effective in lowering blood glutamate levels. Blood samples were taken from 10 critically ill patients immediately before initiation of hemofiltration and after 1, 2, 4, 6, and 12 h, for a total of 6 blood samples. Samples were sent for determination of glutamate, glutamate oxaloacetate transaminase (GOT), glutamate pyruvate transaminase (GPT), hemoglobin, hematocrit, urea, creatinine, glucose, sodium, potassium, platelet, and white blood cell (WBC) levels. There was a statistically significant reduction in blood glutamate levels at all time points compared to baseline levels. There was no difference in levels of GOT or GPT. Hemofiltration can be a promising method of reducing blood glutamate levels, especially in critically ill patients where hemodialysis and peritoneal dialysis may be contraindicated.

Pathologically elevated glutamate concentrations in the brain's extracellular fluid are associated with several acute and chronic brain insults. Studies have demonstrated that by decreasing the concentration of glutamate in the blood, thereby increasing the concentration gradient between the brain and the blood, the rate of brain-to-blood glutamate efflux can be increased. Blood glutamate scavengers, pyruvate and oxaloacetate have shown great promise in providing neuroprotection in many animal models of acute brain insults. However, glutamate scavengers' potential systemic toxicity, side effects and pharmacokinetic properties may limit their use in clinical practice. In contrast, extracorporeal methods of blood glutamate reduction, in which glutamate is filtered from the blood and eliminated, may be an advantageous adjunct in treating acute brain insults. Here, we review the current evidence for the glutamate-lowering effects of hemodialysis, peritoneal dialysis and hemofiltration. The evidence reviewed here highlights the need for clinical trials.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare autosomal recessive disease, characterized by episodes of unexplained fever, anhidrosis, pain insensitivity despite intact tactile perception, self-mutilating behavior, mental retardation, and autonomic nervous system (ANS) abnormalities. We present a case series of three patients with CIPA who underwent semielective orthopedic surgery under general anesthesia complicated by intraoperative regurgitation, and subsequent aspiration in two of the three cases. All three patients were nil per os (NPO) for at least 8 h prior to surgery. Two patients had their airways maintained with a laryngeal mask airway (LMA), and one patient had an endotracheal tube (ETT). The patients with an LMA suffered aspiration of gastric contents and subsequently developed hypoxic cardiac arrest. Although the patient with an ETT in situ regurgitated intraoperatively, the presence of the ETT prevented aspiration and any further potential complications. We review the perioperative complications typically observed in patients with CIPA and discuss the risks of using an LMA in these patients. We recommend that patients with CIPA always should be considered as having a “full stomach”, regardless of the duration of their NPO status, due to their coexisting ANS abnormalities. Therefore, rapid-sequence induction with an ETT should be utilized for the anesthetic management in every patient with CIPA.