Objective: Covid-19 is associated with a significantly increased risk of macrovascular and microvascular thrombotic complications, especially in critically ill patients with a severe form of the disease. Antithrombotic prophylaxis is an important part of treatment and was being applied using different drugs and dosing schemes during the pandemic. Data comparing various possibilities of antithrombotic therapy in these patients is lacking. The primary endpoint of this study was a retrospective assessment of ICU-free days, hospital-free days, and bleeding or thrombotic complications in critically ill patients with covid-19 pneumonia, who initially received higher doses of anticoagulation therapy either using subcutaneous (s. c.) application of low molecular weight heparin (LMWH) or continuous intravenous (i.v.) infusion of unfractionated heparin (UFH). The secondary endpoint was to compare 30-day mortality. Design: Retrospective cohort study. Setting: Intensive Care Unit (ICU) of a university hospital. Material and methods: A retrospective analysis of medical records of critically ill patients with covid-19 associated pneumonia and acute respiratory failure was performed. Patients were admitted to the ICU from 1. 3. 2020 to 31. 3. 2022 and received higher doses of anticoagulation using s.c. nadroparine or i. v. infusion of UFH at least from the second to eighth day of admission. Results: A total of 153 patients were included in the analysis. Median of ICU-free days at 30 days was 15 days for LMWH group and 12 days for UFH group (p = 0.1932). Median of hospital-free days at 60 days and 90 days was 5,5 days for LMWH group and 0 days pro UFH group (p = 0.5511), 26 days and 23 days (p = 0.6590) respectively. The difference in incidence of thromboembolic complications was not significant (1.96% in LMWH group and 7.84% in UFH group (p = 0.2732)). Minor bleeding complications were more frequent in LMWH group (11.76% vs. 0.98%, p = 0.0058). Logistic regression model found no significant effect of anticoagulation therapy on 30-day mortality. Conclusion: No statistically significant difference was found between both groups in the incidence of thromboembolic complications, the number of ICU-free days, the number of hospital-free days. Logistic regression model proved no effect of anticoagulation type on 30day mortality. In the LMWH group, a higher frequency of minor bleeding complications was observed, while the frequency of major bleeding complications did not increase.
New -onset atrial fibrillation is common in critically ill patients with septic shock and worsens haemodynamics through loss of atrial contraction, shortening of diastolic filling time, decrease in cardiac output, and elevation of filling pressures. In this context, atrial fibrillation is associated with prolonged hospitalisation, a higher risk of ischaemic stroke, and increased mortality. The pathogenesis is multifactorial, combining patient-specific predispositions and triggers associated with critical illness. These include excessive catecholamine release, electrolyte imbalances, autonomic nervous system dysregulation, systemic inflammation, and changes in preload and afterload. Together, these factors enhance atrial arrhythmogenicity and predispose to the development of new -onset atrial fibrillation. Bedside echocardiography enables personalised di- agnosis, treatment, and prevention. Parameters focused on the left atrium aid in the risk stratification of atrial fibrillation, prediction of sinus rhythm maintenance, and selection of an appropriate management strategy (rhythm control vs. rate control). Therefore, a comprehensive and individualised assessment of the left atrium, along with evaluation of diastolic and systolic function of both ventricles, should be an integral part of arrhythmia management in patients with septic shock. This review also provides a practical bedside algorithm to guide phenotype -based management.
Objective: This paper evaluates adherence to traction splint use for suspected femoral midshaft fractures in prehospital care, focusing on patients transported to Level I Trauma Center. Design: Retrospective observational study. Setting: Emergency department, emergency medical service. Material and Methods: A retrospective analysis utilized datasets from the Level I Trauma Center and the Emergency Medical Service in the period of January to December 2023. Initially, 391 patients were searched in both databases. The study included 46 patients with prehospital traction splint application due to suspected femoral fracture and 8 patients with a femoral shaft fracture without traction splint application. Patients without a confirmed femoral shaft fracture and without applied traction splint and those who died during transport to the emergency department were excluded. The following variables were recorded: age and gender, mechanism of injury, Injury Severity Score (ISS), duration of the prehospital setting, administration of analgesics in the prehospital care, operation treatment within the first 24 hours after the injury, presence of other severe injuries, need for blood transfusion in early management, length of stay in the hospital and mortality. Subsequently, the sensitivity and specificity of a traction splint application in patients with femoral shaft fractures were evaluated. Results: A total of 54 patients were evaluated, 34 male (63%), median age was 39 years (IQR 26;73), highenergy mechanism of injury prevailed. Injury severity score was 11 (IQR 9;25), 40% of patients were polytraumatized. The duration of prehospital care was 59 min (IQR 47;72 min). Prehospital analgesics were administered to all patients, all polytraumatized patients received early blood transfusion. Length of stay in the hospital was 15 days (IQR 9;26 days). Mortality was 3.7%. Sensitivity of the correct indication of traction splint application in prehospital care in patients with femoral shaft fracture was 92% in our study, specificity 97%. Conclusion: Currently, a traction splint is a common device used for stabilization of the potential femoral shaft fractures in prehospital settings and in the emergency department. It is important to carefully consider contraindications and femoral fracture level for effective use according to the manufacturer's recommendations for the specific traction splint. The challenge remains the assessment of the fracture level on the prehospital scene. Systematic education significantly influences the recognition and appropriate indication for traction splint application and reflects the high specificity and sensitivity of traction splint application in patients with femoral midshaft fractures in our study.
Lumbar spinal stenosis (LSS, M48.06) is a common degenerative disease of the spine, the incidence of which increases significantly with age. It can be a serious risk factor when performing central nerve blocks. Central blocks, especially spinal anaesthesia, are considered the method of choice for many orthopaedic procedures, including total knee replacement. However, their use in patients with lumbar spinal stenosis requires increased caution. It is documented by a case study described in the judgment of the Supreme Court of the Czech Republic. The patient developed a severe and permanent neurological deficit due to decompensated multi-level lumbar spinal stenosis after total knee replacement performed under general anaesthesia following a failed epidural anaesthesia. The case is presented from both a clinical and legal perspective. Possible pathophysiological mechanisms of neurological damage, in particular the role of volume effect in the narrowed spinal canal, perfusion deficits of nerve structures, and the importance of early diagnosis are discussed. The case emphasizes the need for careful preoperative assessment, thorough postoperative monitoring of neurological functions, and immediate treatment of newly emerging neurological symptoms. For patient safety, lumbar spinal stenosis should prompt at least increased vigilance. Therefore, in some patients, modern general anaesthesia with multimodal analgesia and peripheral nerve blocks may also be a suitable option.
Ionised magnesium (Mg2+) represents biologically active form of total plasmatic magnesium and an essential electrolyte with an impact on cellular functions, metabolism, creation of energy substrates (ATP), myocardial electrical stability and the neuromuscular transmission. Critically ill patients face significant changes in acid-base regulation, distribution of body fluids and hormonal regulations, which render traditional estimates of total magnesium levels insufficiently informative and potentially misleading. This collaborative intersocietal position statement summarizes current state-of-the-art scientific and clinical experiences, resulting in recommendations for introduction of a routine Mg(2+)measurement in the critical care practice. An availability of Mg(2+)measurement in selected groups of patients is desirable in relation to new methods in the intensive care practice and is considerably supported by the known deficit of magnesium in the general population. The Mg2+ estimates are suitable for the intensive care units and the critically ill in Czechia. The prominent indications are especially regional citrate anticoagulation and renal failure, in patients with heart failure and a risk of arrhythmias including perioperative arrhythmias at the complex cardiovascular centres. Furthermore, the measurements are recommended in diabetic and septic patients. Mg(2+)should be taken everywhere in shock accompanied with significant shifts in body fluids and acid-base regulation associating with a positive balance of fluids followed by a de-resuscitation phase and a subsequent fluid elimination. The measurement should be available 24/7 as part of the point-of-care analysis similarly as the level of ionised calcium (Ca2+).
