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Background The aim of this study was to compare the estimated glomerular filtration rate (eGFR) from serum creatinine (eGFRcrea) and cystatin C (eGFRcys) in patients with elevated serum trough levels of gentamicin before the next planned dose during treatment in the intensive care unit (ICU). Methods This was a retrospective observational study. Patients who stayed in an ICU, received a once-daily dose of gentamicin, and who had results from all serum gentamicin trough levels, eGFRcrea and eGFRcys analyses were included in the study. Overdosed patients were defined as those with serum gentamicin trough levels above 1 mg/L before the next dose. Gentamicin was measured by a particle-enhanced turbidimetric immunoassay (PETIA). Creatinine and cystatin C were measured by standardized methods. Results The median age (range) was lower in all patients with gentamicin concentration measurements than in overdosed patients (67 [19–96] vs. 75 [48–99] years, respectively; p 2 vs. 41 [29–58] mL/min/1.73 m2, respectively; p 2 vs. 66 [54–93] mL/min/1.73 m2, respectively; p Conclusions Overdosed patients had both a lower eGFRcrea and eGFRcys than controls. Elderly patients are the most commonly overdosed patients. We recommend measuring cystatin C and calculating the eGFRcys and combined equation (eGFRcrea + cys) in ICU patients over 65 years of age, which would enable improved gentamicin dosage adjustments.

Background: Since December 2019, SARS-Co-2 virus has infected millions of people worldwide. In patients with COVID-19 pneumonia in need for oxygen therapy or mechanical ventilation, dexamethasone 6 mg per day is currently recommended. However, the dose of 6 mg of dexamethasone is currently being reappraised and may miss important therapeutic potential or may prevent a potential deleterious effects of a higher doses of corticosteroids. Methods: REMED is a prospective, open-label, randomised controlled trial testing superiority of dexamethasone 20 mg (dexamethasone 20 mg on day 1–5, followed by dexamethasone 10 mg on day 6–10) vs 6 mg administered once daily intravenously for 10 days in adult patients with moderate or severe ARDS due to confirmed COVID-19. 300 participants will be enrolled and followed up for 360 days after randomization. Patients will be randomised in a 1:1 ratio into one of the two treatment arms. Following stratification factors will be applied: age, Charlson Comorbidity index, CRP levels and trial centre. Primary endpoint is number of ventilator-free days (VFDs) at 28 days after randomisation. Secondary endpoints are mortality from any cause at 60 days after randomisation; Dynamics of inflammatory marker, change in WHO Clinical Progression Scale at Day 14; Adverse events related to corticosteroids and independence at 90 days after randomisation assessed by Barthel Index.The long-term outcomes of this study are to assess long-term consequences on mortality and quality of life at 180 and 360 days. The study will be conducted in the intensive care units (ICUs) of ten university hospitals in the Czech Republic. Discussion: We aim to compare two different dose of dexamethasone in patients with moderate to severe ARDS undergoing mechanical ventilation regarding efficacy and safetyTrial registration: EudraCT No.:2020-005887-70 and ClinicalTrials.gov Identifier: NCT04663555 on December 11, 2020 on ClinicalTrials.gov

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma. It is the second most frequent nosocomial infection and the leading cause of death from infection in critically ill patients. Hospital-acquired and, particularly, ventilator-associated pneumonia prolong the hospital stay and increase treatment costs. The clinical signs of pneumonia are rather non-specific, with limited possibilities to distinguish the lung condition from other nosological entities. The yield, effectiveness and cost of new rapid diagnostic procedures as well as early biochemical markers specific for pneumonia have not been sufficiently verified and clinical translation of technological innovations is slow. In bedside clinical practice, the diagnosis continues to be based on clinical examination together with imaging methods, most frequently X-ray. The spectrum of etiologic agents changes, with an increase in the prevalence of multidrug-resistant (MDR) bacterial pathogens. Initial antibiotic therapy, particularly in critically ill ventilated patients, needs to include broad-spectrum agents due to the risk of the presence of MDR bacteria. The likelihood of successful treatment may be increased by regular updates of recommendations for adequate initial antibiotherapy with regard to the epidemiological situation and knowledge of bacterial resistance to antimicrobials in a particular hospital and region. As part of the current valid guidelines, recommendation were newly translated; however, their level of evidence is often very low and the strength of recommendation is mostly weak or moderate. Their benefit to everyday practice is questionable. The article points to changes brought about by the recent European guidelines published in fall 2017 and summarizes current issues concerning HAP pathogens in intensive care units in the Czech Republic.

Background. Patients with significant medical and social problems resulting from impaired perfusion of the upper limbs caused by micro- or macro-angiopathy are now frequent in clinical practice. Vasospastic disease of the upper limbs of combined origin is a difficult condition to treat by conservative methods and therapeutic strategies are usually multidisciplinary. In addition to standard pharmacotherapy, treatment may involve regional anaesthesia, thoracoscopic or radiofrequency sympathectomy and surgical treatment of defects, including plastic surgery. Methods. This paper describes our successful work in the treatment of upper limb critical ischemia using radiofrequency upper thoracic sympathectomy. Results. In three case reports we present the results of radiofrequency thermolysis applied to treat patients with chronic defects of the hand and fingers. These patients were diagnosed with upper limb critical ischemia of combined origin, standard conservative treatment methods failed and surgical intervention was originally not indicated, however, radiofrequency thermolysis proved to be beneficial. Conclusions. Radiofrequency thoracic sympathectomy could improve peripheral perfusion of the upper limbs and thereby contribute to healing of chronic defects, reduction of pain and improvement in the quality of life of the patients.

Superior laryngeal (SL) neuralgia is paroxysmal pain above the thyrohyoid membrane. We present a case of SL neuralgia that was resistant to conservative treatment and eventually required surgical intervention. The patient was a 39-year-old woman with a 5-year history of debilitating pain above the thyroid cartilage. After having undergone different imaging scans with negative results, she tried various treatments (e.g., antibiotics, analgesics, stellate ganglion block, radiofrequency SL neurotomy, and stereotactic radiosurgery), all of which were ineffective. Finally, she underwent bilateral surgical SL neurotomy. Postoperatively, she immediately noticed a significant alleviation of her pain. Her postoperative course was completely uneventful, as she experienced no dysphagia or dysphonia, even transiently. One month later, she no longer required regular painkillers, and at 14 months, she remained essentially pain-free. While medical management remains the treatment of choice for SL neuralgia, we recommend that refractory cases be treated initially with a neural block with local anesthesia. Patients who do not respond are candidates for surgery. We consider selective peripheral SL neurotomy to be safe and effective when performed by experienced hands. We also discuss the difficulties of managing SL neuralgia.

Background: Hospital-acquired pneumonia (HAP) is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of HAP. This project was aimed at collecting multicenter epidemiological data on patients with HAP in the Czech Republic and comparing them with supraregional data. Methods: This prospective, multicenter, observational study processed data from a database supported by a Czech Ministry of Health grant project. Included were all consecutive patients aged 18 and over who were admitted to participating intensive care units (ICUs) between 1 May 2013 and 31 December 2014 and met the inclusion criterion of having HAP. The primary endpoint was to analyze the relationships between 30-day mortality (during the stay in or after discharge from ICUs) and the microbiological etiological agent and adequacy of initial empirical antibiotic therapy in HAP patients. Results: The group dataset contained data on 330 enrolled patients. The final validated dataset involved 214 patients, 168 males (78.5%) and 46 females (21.5%), from whom 278 valid lower airway samples were obtained. The mean patient age was 59.9 years. The mean APACHE II score at admission was 21. Community-acquired pneumonia was identified in 13 patients and HAP in 201 patients, of whom 26 (12.1%) had early-onset and 175 (81.8%) had late-onset HAP. Twenty-two bacterial species were identified as etiologic agents but only six of them exceeded a frequency of detection of 5% ( Klebsiella pneumoniae 20 .4%, Pseudomonas aeruginosa 20 .0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6 .2% and Burkholderia cepacia complex 5.8%). Patients infected with Staphylococcus aureus had significantly higher rates of early-onset HAP than those with other etiologic agents. The overall 30-day mortality rate for HAP was 29.9%, with 19.2% mortality for early-onset HAP and 31.4% mortality for late-onset HAP. Patients with late-onset HAP receiving adequate initial empirical antibiotic therapy had statistically significantly lower 30-day mortality than those receiving inadequate initial antibiotic therapy (23.8% vs 42.9%). Patients with ventilator-associated pneumonia (VAP) had significantly higher mortality than those who developed HAP with no association with mechanical ventilation (34.6% vs 12.7%). Patients having VAP treated with adequate initial antibiotic therapy had lower 30-day mortality than those receiving inadequate therapy (27.2% vs 44.8%). Conclusions: The present study was the first to collect multicenter data on the epidemiology of HAP in the Central European Region, with respect to the incidence of etiologic agents causing HAP. It was concerned with relationships between 30-day patient mortality and the type of HAP, etiologic agent and adequacy of initial empirical antibiotic therapy.

Aim: To determine the accuracy of the modified Mallampati test for predicting difficult tracheal intubation. Design: A cross-sectional, clinical, observational, non-blinded study. A quality analysis of anesthetic care. Setting. Operating theatres and department of anesthesiology in a university hospital. Material and methods: Following the local ethics committee approval and patients' informed consent to anesthesia, all adult patients (> 18 yrs) presenting for any type of non-emergency surgical procedures under general anesthesia requiring endotracheal intubation were enrolled. Prior to anesthesia, Samsoon and Young's modification of the Mallampati test (modified Mallampati test) was performed. Following induction, the anesthesiologist described the laryngoscopic view using the Cormack-Lehane scale. Classes 3 or 4 of the modified Mallampati test were considered a predictor of difficult intubation. Grades 3 or 4 of the Cormack-Lehane classification of the laryngoscopic view were defined as impaired glottic exposure. The sensitivity, specificity, positive and negative predictive value, relative risk, likelihood ratio and accuracy of the modified Mallampati test were calculated on 2x2 contingency tables. Results: Of the total 1,518 patients enrolled, 48 had difficult intubation (3.2%). We failed to detect as many as 35.4% patients in whom glottis exposure during direct laryngoscopy was inadequate (sensitivity 0.646). Compared to the original article by Mallampati, we found lower specificity (0.824 vs. 0.995), lower positive predictive value (0.107 vs. 0.933), higher negative predictive value (0.986 vs. 0.928), lower likelihood ratio (3.68 vs. 91.0) and accuracy (0.819 vs. 0.929). Conclusion: When used as a single examination, the modified Mallampati test is of limited value in predicting difficult intubation.

To assess the influence of gender on the course of rocuronium-induced neuromuscular block following a single bolus dose of 2 x ED(95) (0.6 mg kg(-1)).Following the ethics committee approval and informed consent, 245 patients (121 men, 124 women) scheduled for elective general surgery under TIVA with muscle relaxation were studied. After rocuronium 0.6 mg kg(-1), the onset time for maximal depression of T(1), clinical duration until 25 % recovery and recovery index (T(1) from 25 to 75 %) were determined with TOF-Watch SX accelerometric monitor. The data for male and female groups were compared with appropriate statistical tests (Student's unpaired t-test, Mann-Whitney Rank Sum Test and Fisher's exact test).Men were significantly larger (p0.001) and heavier (p0.05) than women, but the body mass index was comparable (ns). The onset time was shorter in females [92.5 (SD 14.2) vs. 104.7 (12.2) s, p0.0001]. Clinical duration was increased in females [43.1 (7.9) vs. 31.3 (5.5) min; p0.0001], while the recovery index was identical in both groups [14.7 (5.0) min in females and 14.8 (4.0) min in males; ns].Women are more sensitive than men to the dose 0.6 mg kg(-1) of rocuronium. Under the study conditions described, the onset time was shortened and the clinical duration increased in female patients. This suggests that the routine dose of rocuronium should be reduced in women.

Cil:Cilem teto pilotni studie bylo ověřit uspěsnost perkutanni radiofrekvencni termokoagulace při lecbě ischemických stavů hornich koncetin. Metodika:U indikovaných pacientů byla provedena termokoagulace horniho hrudniho sympatiku pomoci kontrolovane leze v urovni Th2 a Th3. Byla sledovana uspěsnost výkonu pomoci subjektivnich i objektivnich kriterii a frekvence komplikaci. Celkem byl ve sledovanem obdobi proveden výkon u 20 pacientů. Výsledky:Akutni uspěsnost metody byla v nasem souboru 90%. K rekurenci ischemických obtiži doslo u 28 % nemocných. Po 24 měsicich byl výrazný ucinek výkonu patrný jestě u 75 % pacientů. Umrti v souvislosti s výkonem ani zavažne komplikace nebyly zaznamenany. Z meně zavažných komplikaci se vyskytly přechodne bolesti v zadech a otok horni koncetiny nasledkem reperfuze. Zavěry:Perkutanni radiofrekvencni koagulace v nasem souboru ukazala statisticky významne zlepseni prokrveni horni koncetiny, sniženi cetnosti ischemicke bolesti při soucasně nizke frekvenci komplikaci. Dalsi studie jsou nezbytne pro potvrzeni tohoto výsledku.

Aims: To compare the pharmacodynamics of 0.6 mg kg-1 rocuronium in young and older patients of both genders during total intravenous anesthesia. Methods: Following local ethics committee approval and informed consent, patients scheduled for surgery under total intravenous anesthesia (propofol/sufentanil) were divided into 4 study groups: 37 males aged 20-40, 40 males aged 60-75 yrs, 43 females aged 20-40 and 38 females aged 60-75 yrs. Neuromuscular block following rocuronium (0.6 mg kg-1) was monitored: train-of-four [TOF] stimulation of the ulnar nerve at 15-s intervals, EMG of the adductor pollicis muscle. The onset time (from application of rocuronium to maximum depression of T1), clinical duration (from application to 25% recovery of T1), and time to full spontaneous recovery (from application to TOF-ratio ≥ 0.9) were determined for each patient. The Kruskal-Wallis test was used to compare differences between groups; P

To determine the inter-observer reproducibility of 15 tests used for predicting difficult tracheal intubation (DI).Following local ethics committee approval and informed consent, 101 volunteers were examined by two assessors using 15 tests for predicting DI. The two assessors who were blinded to the results of the other, examined each volunteer independently. Cohen's kappa (κ) or first-order agreement coefficient (AC1) were used to measure agreement between assessor ratings on a qualitative scale. Agreement between two quantitative outcomes was described using the intraclass correlation coefficient (ICC) and Pearson's (PCC) or Spearman's (SCC) correlation coefficients. The following interpretation of the coefficients was used: poor (0.20), fair (0.21-0.40), satisfactory (0.41-0.60), good (0.61-0.80), and excellent (0.81-1.00).Respective coefficients of inter-rater agreement and correlation coefficients were determined for the following parameters: pathologies associated with DI (κ=0.662, AC1=0.990), clinical impression (κ=-0.013, AC1=0.969), modified Mallampati test (κ=0.503, AC1=0.861), upper lip bite test (κ=0.370, AC1=0.897), temporo-mandibular joint movement (κ=0.088, AC1=0.797), max. anteroflexion of C-spine (ICC=0.136, SCC=0.391), max. retroflexion of C-spine (ICC=0.020, SCC=0.284), mandibular length (ICC=0.301, SCC=0.553), neck circumference (ICC=0.832, SCC=0.928), hyo-mental distance (ICC=0.378, SCC=0.472), thyro-mental distance (ICC=-0.002, PCC=0.265), sternomental distance (ICC=0.674, PCC=0.815), and finally, inter-incisor gap (ICC=0.695, PCC=0.785). Two tests (positive history of DI and retrogenia), were excluded from calculation because no positive cases were found.Best inter-rater agreement was found for the assessment of neck circumference while the highest discrepancies between raters were in goniometrically-measured mobility of the C-spine. Many of the pre-operative airway tests had only fair inter-observer reproducibility. This may be one reason why models for predicting difficult intubation are not universally reliable.

Extreme lateral interbody fusion (XLIF) is a method for stabilization of the lumbar spine. Intraoperatively, the surgeon identifies the lumbar nerve roots with a stimulator to prevent their injury. The objective of this study was to determine the extent to which shallow rocuronium-induced neuromuscular block must be intraoperatively reversed for reliable identification of nerve roots. General anesthesia (midazolam–propofol–sufentanil–oxygen/air/sevoflurane–rocuronium) was administered to all patients. Train-of-four (TOF) stimulation of the ulnar nerve at 15-s intervals and electromyographic response of the adductor pollicis muscle were used. During operation, the surgeon stimulated the lumbar nerve roots (5–10 mA) to identify their course. At the appearance of two twitches to the TOF stimuli, sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg) was administered. When the response to nerve root stimulation appeared, the TOF ratio was recorded. When the response to nerve root stimulation with 10 mA became detectable, the median (range) TOF ratios were 0.67 (0.50–0.81) and 0.65 (0.42–0.71) after sugammadex and neostigmine, respectively. Similarly, TOF ratios at the first detectable response to stimulation with 5 mA were 0.88 (0.67–0.93) and 0.83 (0.61–0.93). After sugammadex and neostigmine, the respective intervals until TOF ratio ≥0.90 were 2.0 (0.8–3.3) and 15.9 (7.3–28.8) min. Intraoperative reversal of shallow rocuronium-induced block with either sugammadex or neostigmine is an efficient method. For reliable detection of lumbar nerve roots with a stimulating current of 10 mA, the block should be reversed to a TOF ratio of at least 0.70. For a current intensity of 5 mA, the TOF ratio should reach 0.90.

Percutaneous radiofrequency (RF) thoracic sympathectomy is an alternative method to surgical procedures for the treatment of acral ischemia in Raynaud phenomenon. The procedure is indicated if conservative therapy fails to provide sufficient relief. The aim of this study was to compare classic T2 and T3 RF thermolesioning with a less invasive procedure at the level of T2 only.Fifty adult patients, American Society of Anesthesiologists (ASA) classification I to III, were randomly assigned to 1 of 2 groups. T2 and T3 thoracic RF thermolesion was performed in 1 group, whereas T2 thermolesion with local application of 0.5 mL of 6% phenol was delivered in the second group. Changes in cold perception, pain, and quality of life were assessed using a questionnaire. Blood circulation in the upper extremity was evaluated using infrared thermography. Patients were observed for a period of 3 months.A significant decrease in pain according to visual analog scale (P0.001), increase in peripheral temperature in the upper extremities (P0.001), and improvement in quality of life were observed in both groups of patients after the procedure. Susceptibility to cold-provoked vasospasm was not significantly affected in either group. There was no significant difference between the 2 groups in any parameter apart from the duration of the procedure.Thoracic RF upper sympathectomy is an effective method in the treatment of resistant forms of Raynaud phenomenon. A single-shot procedure at the level of T2 may be preferable because of the shorter procedure duration of this technique.