Atelectasis caused by lung injury leads to increased intrapulmonary shunt, venous admixture, and hypoxaemia. Lung recruitment manoeuvres aim to quickly reverse this scenario by applying increased airway pressures for a short period of time which meant to open the collapsed alveoli. Although the procedure can improve oxygenation, but due to the heart-lung and right and left ventricle interactions elevated intrathoracic pressures can inflict serious effects on the cardiovascular system. The purpose of this paper is to give an overview on the pathophysiological background of the heart-lung interactions and the best way to monitor these changes during lung recruitment.

Systemic inflammatory response with rhabdomyolysis and consequent multiorgan failure is a known sequela of psychotropic drug abuse. However, in cases with uncertain past medical history the initial diagnosis can be challenging. Here we report the case of a 21-year-old male who was admitted to the intensive care unit with severe neurological impairment caused by amphetamine intoxication. First laboratory investigations revealed extremely high serum procalcitonin (PCT) levels reaching a maximum concentration of 1640 ng/mL on the second day of observation. Although PCT has high sensitivity and specificity in differentiating bacterial sepsis from nonbacterial inflammation, our case report shows for the first time that it can be extremely elevated following serious amphetamine intoxication without bacterial infection.

Macro, and microcirculatory effects of crystalloids and colloids are difficult to compare, because interventions to achieve haemodynamic stability seldom follow similar criteria. Our aim was to compare the effects of crystalloids and colloids on the microcirculation during free flap surgery when management was guided by detailed haemodynamic assessment. A randomised, controlled clinical trial. The investigation was performed at the University of Szeged, Hungary. Patients undergoing maxillofacial tumour resection and free flap reconstruction were randomised into groups treated with either intra-operative crystalloid (Ringerfundin, n = 15) or colloid (6% hydroxyethyl starch, HES, n = 15) solutions. Macrohaemodynamics were monitored by a noncalibrated device (PulsioFlex-PULSION). Central venous oxygen saturation, venous-to-arterial PCO2-gap, lactate levels and urine output were measured hourly. Maintenance fluid was Ringerfundin (1 ml kg−1 h−1), and a multimodal, individualised, approach-based algorithm was applied to guide haemodynamic support. Hypovolaemia was treated with Ringerfundin or HES fluid boluses, respectively. The microcirculatory effects were assessed by laser-Doppler flowmetry (PeriFlux 5000 LDPM), with the probe placed on the flap and on a control area. Measurements were performed after the flap was prepared, then 1 and 12 h later. The primary end-point was microcirculatory perfusion as determined by laser-Doppler flowmetry. There was no difference between the groups regarding patient characteristics. Both groups remained haemodynamically stable throughout due to the use of approximately a 1.5 times higher total fluid volume in the Ringerfundin group than in the HES group: mean ± SD: 2581 ± 986 and 1803 ± 497) ml, respectively, (P = 0.011). There was no significant difference in the microcirculatory blood flow between the groups. Our results showed that when fluid management was guided by detailed haemodynamic assessment, more crystalloid than colloid was needed to maintain haemodynamic stability, but there was no difference between the effects of crystalloids and colloids on the microcirculation. ClinicalTrials.gov NCT03288051.

Purpose. To investigate whether absolute value of procalcitonin (PCT) or the change (delta-PCT) is better indicator of infection in intensive care patients.Materials and Methods.Post hocanalysis of a prospective observational study. Patients with suspected new-onset infection were included in whom PCT, C-reactive protein (CRP), temperature, and leukocyte (WBC) values were measured on inclusion (t0) and data were also available from the previous day (t-1). Based on clinical and microbiological data, patients were groupedpost hocinto infection- (I-) and noninfection- (NI-) groups.Results. Of the 114 patients, 85 (75%) had proven infection. PCT levels were similar att-1: I-group (median [interquartile range]): 1.04 [0.40–3.57] versus NI-group: 0.53 [0.16–1.68],p=0.444. Byt0PCT levels were significantly higher in the I-group: 4.62 [1.91–12.62] versus 1.12 [0.30–1.66],p=0.018. The area under the curve to predict infection for absolute values of PCT was 0.64 [95% CI = 0.52–0.76],p=0.022; for percentage change: 0.77 [0.66–0.87],p<0.001; and for delta-PCT: 0.85 [0.78–0.92],p<0.001. The optimal cut-off value for delta-PCT to indicate infection was 0.76 ng/mL (sensitivity 80 [70–88]%, specificity 86 [68-96]%). Neither absolute values nor changes in CRP, temperature, or WBC could predict infection.Conclusions. Our results suggest that delta-PCT values are superior to absolute values in indicating infection in intensive care patients. This trial is registered with ClinicalTrials.gov identifier:NCT02311816.

Pharmacological treatment of major psychiatric conditions (eg, schizophrenia, bipolar disorder) is exceptionally difficult during pregnancy. Despite all efforts, medication-resistant life-threatening mental deterioration can emerge with the urgent need for rapid and effective intervention. In these cases, electroconvulsive therapy (ECT) may represent the only valid and safe therapeutic option. Here, we present the challenging medical case of a 31-year-old primigravida with a general medical history of obesity and hypertension, previously diagnosed with bipolar affective disorder, now presenting with severe, therapy-resistant manic agitation. Full symptomatic remission was achieved and preserved with ECT given between the 7th and 22nd gestational weeks, the pregnancy reached full term, and a healthy child was born by cesarean delivery performed because of preeclampsia. Although it is unusual to start ECT this early in pregnancy, with the thorough assessment of potential risk factors and preventive measures taken, it can be the most effective and presumably the least risky treatment approach. By delineating key aspects of both the psychiatric and anesthetic management of this case, we aim to highlight the importance of a close cooperation between all medical fields involved in clinical practice.

Biofeedback (BF) therapy methods have evolved considerably in recent years. The best known is biofeedback training based on heart rate variability (HRV), which is used to treat asthma, depression, stress, and anxiety, among other conditions, by synchronizing the rhythm of breathing and heartbeat. The aim of our research was to develop a methodology and test its applicability using photoplethysmographs and smartphones to conduct biofeedback sessions for frontline healthcare workers under their everyday stressful conditions. Our hypothesis is that such a methodology is not only comparable to traditional training itself, but can make regular sessions increasingly effective in reducing real-life stress by providing appropriate feedback to the subject. The sample consisted 28 participants. Our proprietary method based on HRV biofeedback is able to determine the resonance frequency of the subjects, i.e., the number at which the pulse and respiration are in sync. Our research app then uses visual feedback to help the subject reach this frequency, which, if maintained, can significantly reduce stress. By comparing BF with Free relaxation, we conclude that BF does not lose effectiveness over time and repetitions, but increases it. This paper is our pilot study in which we discuss the method used to select participants, the development and operation of the protocol and algorithm, and present and analyze the results obtained. The showcased results demonstrate our hypothesis that purely IT-based relaxation techniques can effectively compete with spontaneous relaxation through biofeedback. This provides a basis for further investigation and development of the methodology and its widespread use to effectively reduce workplace stress.