8 research outputs found
DijagnostiÄko-terapijski pristup kompleksnoj koagulopatiji uslijed recidivirajuÄeg krvarenja iz mokraÄnog sustava
Coagulation disorders in critically ill patients presenting with bleeding can be multicausal.
The drugs applied can interfere and impair the coagulation cascade. Point-of-care (POC) coagulation
assays may resolve difficult therapeutic situations in critical illness. We report on a 73-year-old
critically ill male patient with massive hematuria after bladder lithotripsy. The patient was on low molecular
weight heparin therapy due to recent pulmonary embolism. He was subjected to repeated surgical
hemostasis which was ineffective despite massive transfusion protocol and normal standard coagulation
profile. Additional POC coagulation assays were obtained and were indicative of platelet dysfunction.
We revised his medical therapy and suspected the possible drug influence on platelet aggregation. After
discontinuation of target drug, platelet aggregation increased whereas hematuria stopped. Coagulation
disorders in intensive care unit patients are often multifactorial. Standard laboratory tests are unreliable
in complex refractory bleeding and may result in inappropriate therapeutic decisions. Stepwise approach
with assessment of clinical parameters, present therapy, and a combination of POC coagulation tests is
the key to optimal therapeutic management.PoremeÄaji koagulacije kod bolesnika u jedinici intenzivnog lijeÄenja (JIL) su Äesto složeni. Farmakoterapija tijekom
bolesti može poremetiti fizioloÅ”ki proces zgruÅ”avanja krvi. Dodatni koagulacijski testovi uz standardni dijagnostiÄki pristup
kod nastale refraktorne koagulopatije omoguÄuju ciljano terapijsko djelovanje i postizanje hemostaze. Bolesnik u dobi od
73 godine u JIL se prezentirao masivnim krvarenjem iz mokraÄnog mjehura nakon litotripsije i uvoÄenja terapijske doze
niskomolekularnog heparina zbog akutne pluÄne embolije. Podvrgnut je viÅ”estrukim pokuÅ”ajima kirurÅ”ke hemostaze i masivnom
transfuzijskom protokolu koji nisu doveli do prestanka krvarenja. Standardni koagulacijski testovi nisu ukazivali na
poremeÄaj hemostaze. Dodatnim testovima utvrÄena je disfunkcija cirkulirajuÄih trombocita. Nakon iskljuÄivanja lijekova
koji mogu utjecati na njihovu funkciju doŔlo je do oporavka trombocitne funkcije i postizanja hemostaze. Koagulacijski
poremeÄaji kod bolesnika u JIL-u su multifaktorski. Polipragmazija kod teÅ”ko oboljelih može utjecati na fizioloÅ”ki proces
zgruŔavanja krvi. Standardni koagulacijski testovi su nedovoljno pouzdani za razrjeŔavanje kompleksnih koagulopatija. Sveobuhvatni
kliniÄki pristup, dodatni koagulacijski testovi i uzimanje u obzir utjecaja farmakoterapije na koagulacijsku kaskadu
vodi do optimalnog terapijskog pristupa i postizanja hemostaze
Are we ready for end of life decisions in intensive medicine?
Cilj istraživanja: Usporediti stavove intenzivista KliniÄkog bolniÄkog centra Osijek o kraju života u jedinicama intenzivnog lijeÄenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje se sastojalo od dva dijela: provoÄenje anonimne ankete meÄu lijeÄnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolniÄkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da veÄina lijeÄnika nije primjenjivala smjernice za unaprijeÄenje palijativne skrbi u JIL-u te da postoje dileme oko etiÄnosti ograniÄenja mjera umjetnog održavanja života. Kao glavni razlozi neprovoÄenja smjernica bili su identificirani nedostatak pravne zaÅ”tite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je znaÄajno velik broj smrti nakon neuspjeÅ”ne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovoÄenju KPR-a i izostavljanju odreÄene
mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograniÄavanju mjera i postupaka umjetnog održavanja života, veÄina lijeÄnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. ZakljuÄak: Navedeni rezultati ukazuju na potrebu za poboljÅ”anjem postupanja u donoÅ”enju odluka o kraju života u JIL-u.Objectives: To compare the attitudes of intensive care physicians at Clinical Hospital Center Osijek regarding end-of-life care in intensive care units (ICUs) with actual practice. Participants and methods: The study consisted of two parts: conducting an anonymous survey among specialist physicians working in ICUs and retrospective analysis of data on deceased patients in 2022, collected from the Hospital Information System (HIS). Results: The survey revealed that the majority of physicians did not adhere to guidelines for improving palliative care in ICUs and that there were ethical dilemmas regarding the limitation of life-sustaining measures. The main reasons for non-adherence to the guidelines were identified as a lack of legal protection and fear of colleaguesā and familiesā perception. Analysis of data from the HIS identified a significantly higher number of deaths following unsuccessful cardiopulmonary resuscitation (CPR) compared to the rest of Europe, as well as a lack of written documentation of decisions to withhold CPR and specific life-sustaining measures. Although there was a protocol for making decisions on life-sustaining measures limitations, the majority of physicians were unaware of its existence and did not complete it. Conclusion: These findings highlight the need for improvement in decision-making regarding end-of-life care in ICUs
Role of continuous renal replacement therapy in severe rhabdomyolysis with multiple organ failure due to methandriol abuse
Kontinuirane metode bubrežnoga nadomjesnog lijeÄenja posljednjih godina imaju sve veÄu ulogu pri zbrinjavanju bolesnika u jedinicama intenzivnog lijeÄenja. Prednosti koje one pružaju u odnosu prema
konvencionalnim, intermitentnim metodama pogoduju kritiÄno oboljelima, zbog Äega je ova metoda vrlo privlaÄna pri izboru terapijskog pristupa u jedinicama intenzivnog lijeÄenja. Primjer je kliniÄki prikaz dotad zdravoga ÄetrdesetÅ”estogodiÅ”njeg muÅ”karca koji je primljen u jedinicu intenzivnog lijeÄenja zbog iznenadno nastalog poremeÄaja stanja svijesti, respiratorne insuficijencije, cirkulacijske nestabilnosti, rabdomiolize, anurije i akutnoga bubrežnog oÅ”teÄenja nepoznatog uzroka. Bolesnik je mehaniÄki ventiliran, volumno resuscitiran,
nalažuÄi cirkulacijsku potporu vazopresorima. UnatoÄ inicijalno poduzetim mjerama intenzivnog lijeÄenja nije doÅ”lo do oporavka diureze i hemodinamske stabilizacije uz daljnje pogorÅ”anje stanja. Zbog perzistirajuÄe hiperkalemije opasne za život, metaboliÄke acidoze, uremije i rabdomiolize zapoÄeti su kontinuirano bubrežno nadomjesno
lijeÄenje (engl. Continuous renal replacement therapy ā CRRT), uz istodobno pružanje potpore naruÅ”enim organskim sustavima, i traganje za moguÄim uzrokom prezentirane kliniÄke slike. Nakon tjedan dana kontinuirane potpore naruÅ”enoj bubrežnoj funkciji doÅ”lo je do oporavka stanja svijesti, hemodinamske stabilizacije, odvajanja od strojne ventilacije i oporavka diureze uz normalizaciju bubrežne funkcije. Ciljanom toksikoloÅ”kom analizom urina potvrÄeno je da su anaboliÄki steroidi koje je bolesnik uzimao moguÄi uzrok rabdomiolize i bubrežnog oÅ”teÄenja. Bolesnik je desetog dana otpuÅ”ten iz jedinice intenzivnog lijeÄenja u dobrom opÄem stanju i uredne bubrežne funkcije. Kontinuirane metode bubrežnoga nadomjesnog lijeÄenja uÄinkovit su naÄin zbrinjavanja akutnoga bubrežnog oÅ”teÄenja u kritiÄno oboljelih zbog nastaloga multiorganskog zatajenja razliÄite etiogeneze.Continuous methods of renal replacement therapy (CRRT) in the treatment of acute kidney failure gained popularity in past years in the intensive care units. Compared to conventional methods (intermittent
hemodialysis), they offer more hemodynamic stability, achievement of electrolytes and body fluids homeostasis, and have options for blood purification and controlling body temperature simultaneously. All these advantages make them the preferred method for the treatment of acute kidney injury in patients who are hemodynamically unstable with multiorgan failure from any cause. In this case report we describe a previously healthy 46āyear-old man who came in the intensive care unit in the comatose state, hemodynamically unstable, with anuria and acute respiratory failure. The initial laboratory results showed rhabdomyolysis, acute renal failure, severe metabolic acidosis and hyperkalemia. According to the clinical examination and laboratory tests, he was critically ill with multiorgan failure and systemic inflammatory response synsrom due tu an trigger. Acute intoxication with an unknown substance was suspected. He was mechanically ventilated, with fluid resuscitation and high doses of vasopressors for the maintenance of perfusion pressures. Despite the initial treatment, hemodynamic
instability, anuria and acute renal failure persisted with the worsening of clinical picture and control laboratory tests. We started continuous renal replacement therapy for seven days trying to find the cause for his clinical condition. Combination of heteroanamnesis with target toxicology diagnostic tests found that the use of anabolic steroids might have triggered rhabdomyolysis with acute renal failure. After few days
he was fully awake, spontaneously breathing, circulatory stable with the return to normal renal function and diuresis. Control laboratory results returned to normal values. He was discharged from intensive care unit
after ten days. Continuous methods of renal replacement therapy are a valuable method for the management of acute kidney failur
Short bowel syndrome in septic patients: a case report
Sindrom kratkog crijeva oÄituje se malapsorpcijom koja je posljedica opsežne resekcije crijeva. Duljina crijeva preostaloga nakon kirurÅ”ke resekcije smatra se glavnom odrednicom ishoda u tih bolesnika. LijeÄenje sindroma složeno je i nalaže multidisciplinarni pristup radi smanjenja morbiditeta i mortaliteta. Ovaj prikaz opisuje 60-godiÅ”nju bolesnicu koja je podvrgnuta multiplim resekcijama crijeva, Å”to je rezultiralo preostalim tankim crijevom duljine 30 cm postduodenalno i terminalnom jejunostomom. Njezin boravak u jedinici intenzivnog lijeÄenja zakomplicirao se zbog razvoja respiratornog zatajenja, bilateralne pneumonije i sepse. Pacijentica je mehaniÄki ventilirana i lijeÄena antimikrobnim lijekovima u skladu s rezultatima mikrobioloÅ”kih pretraga i antibiogramom. Inicijalno je zapoÄeta potpuna parenteralna prehrana, dok se enteralna prehrana uvodila postupno. U lijeÄenju bolesnice sudjelovao je multidisciplinarni tim sastavljen od anesteziologa, kirurga i gastroenterologa. Nakon Äetiri mjeseca bolniÄkog lijeÄenja pacijentica je otpuÅ”tena kuÄi opremljena tuneliranim srediÅ”njim venskim kateterom, a parenteralna je prehrana nastavljena u kuÄnim uvjetima u kombinaciji s peroralnim hranjenjem.Short bowel syndrome is a global malabsorption state resulting from an inadequate length of intestine following intestinal resection. Residual bowel length is generally considered to be the primary determinant
of outcome in these patients. This complex condition requires a multidisciplinary approach to reduce morbidity and mortality. In this case report we describe a 60-year-old female patient who underwent multiple bowel resections that resulted in postduodenal small intestine length of 30 cm with an end jejunostomy being formed. Her
intensive care unit stay was complicated with respiratory failure, bilateral pneumonia and sepsis. She was mechanically ventilated and treated with antimicrobial agents according to microbial isolates and antibiograms. Total parenteral nutrition was started immediately after the surgery and enteral nutrition was gradually introduced. A multidisciplinary team consisting of anesthesiologists, surgeons and gastroenterologists participated in her treatment. After four months of hospital treatment the patient was discharged home equipped with a permanent tunneled central venous catheter and continued home parenteral nutrition in combination with oral feeding
Jesmo li spremni za donoŔenje odluka o kraju života u intenzivnoj medicini?
Cilj istraživanja: Usporediti stavove intenzivista KliniÄkog bolniÄkog centra Osijek o kraju života u jedinicama intenzivnog lijeÄenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje se sastojalo od dva dijela: provoÄenje anonimne ankete meÄu lijeÄnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolniÄkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da veÄina lijeÄnika nije primjenjivala smjernice za unaprijeÄenje palijativne skrbi u JIL-u te da postoje dileme oko etiÄnosti ograniÄenja mjera umjetnog održavanja života. Kao glavni razlozi neprovoÄenja smjernica bili su identificirani nedostatak pravne zaÅ”tite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je znaÄajno velik broj smrti nakon neuspjeÅ”ne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovoÄenju KPR-a i izostavljanju odreÄene
mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograniÄavanju mjera i postupaka umjetnog održavanja života, veÄina lijeÄnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. ZakljuÄak: Navedeni rezultati ukazuju na potrebu za poboljÅ”anjem postupanja u donoÅ”enju odluka o kraju života u JIL-u
Poslijeoperacijska sustavna upala nakon velike abdominalne operacije ne mijenja analgetski uÄinak tramadola
Tramadol is a commonly used analgesic in intensive care units (ICUs) for acute
postoperative pain. Conversion of tramadol into active metabolites may be impaired in inflammatory
states. Catechol-O-methyltransferase may influence pain. The aim of the study was to examine differences
in the analgesic effect of tramadol between ICU patients with and without signs of systemic
inflammation. Forty-three patients were admitted to ICU after a major abdominal surgery. The patients
received a dose of 100 mg of tramadol intravenously every 6 hours during the first 24 hours
after surgical procedure. Pain scores were measured by the Numeric Rating Scale before and 30
minutes
after tramadol administration in awake patients. Systemic inflammation was considered
when at least two of the following postoperative parameters were present in the first 24 hours of ICU
admission: fever or hypothermia, tachycardia, pCO2 12000/mm3 or
50 mg/L or/and procalcitonin (PCT)
>0.5 mg/L. Catechol-O-methyltransferase was analyzed postoperatively. Fifteen (34.8%) patients
met the criteria for systemic inflammation. Tramadol was proven to be an effective analgesic for the
treatment of postoperative pain regardless of the presence of systemic inflammation (p<0.05). Lower
perception of pain before tramadol application was observed in patients with systemic inflammation,
but the difference was not significant. A negative correlation was observed between the preoperative
values of CRP and PCT and the analgesic effect of tramadol assessed at the second measurement
point (r=-0.358, p=0.03, and r=-0.364, p=0.02, respectively). Catechol-O-methyltransferase variants
were not in correlation with pain and opioid consumption. Based on our findings, tramadol is effective
in lowering pain scores after major abdominal surgery irrespective of the presence of systemic inflammation.Tramadol je analgetik koji se Äesto rabi za poslijeoperacijsku bol u jedinicama intenzivnog lijeÄenja (JIL). Njegova konverzija
u aktivni metabolit zbiva se putem enzima CYP2D6, funkcija kojega je smanjena u stanjima sustavne upale. Na doživljaj
boli mogu utjecati i varijante katehol-O-metiltransferaze. Cilj istraživanja bio je ispitati razlike u analgetskom uÄinku
tramadola kod bolesnika ovisno o razvoju sustavne upale. Äetrdesettroje bolesnika primljena su u JIL nakon velikih abdominalnih
operacija te su intravenski primili 100 mg tramadola svakih 6 sati tijekom 24 sata. Procjena boli putem numeriÄke
ocjenske ljestvice (NRS) raÄena je prije i 30 minuta nakon primjene tramadola. Smatralo se da bolesnici imaju sustavnu
upalu ako su u prva 24 sata poslijeoperacijski imali barem dva od sljedeÄih kriterija: vruÄica ili hipotermija, tahikardija, pCO2 12000/mm3 ili 50 mg/L i/ili prokalcitonin
(PCT) >0,5 mg/L. Katehol-O-metiltransferaza je analizirana poslijeoperacijski. Kriterije za postojanje sustavne upale imalo
je 15 (34,8%) bolesnika. Tramadol je znaÄajno smanjio bol u odnosu na stanje prije primjene, neovisno o postojanju sustavne
upale (p<0,05 u svim mjerenjima). Bolesnici koji su imali sustavnu upalu imali su nižu percepciju boli prije primjene tramadola
u odnosu na one koji nisu imali sustavnu upalu, no ova razlika nije bila statistiÄki znaÄajna. StatistiÄki znaÄajna negativna
korelacija zabilježena je izmeÄu prijeoperacijskih vrijednosti CRP-a i PCT-a i analgetskog uÄinka tramadola u drugoj
mjernoj toÄki (r=-0,358, p=0,03 i r=-0,364, p=0,02). Katehol-O-metiltransferaza nije povezana s potroÅ”njom analgetika niti
jaÄinom boli. Rezultati ovog istraživanja pokazali su da je tramadol uÄinkovit u smanjenju boli nakon abdominalnih operacijskih
zahvata neovisno o znakovima sustavne upale
Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study
Background: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients.
Methods: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs.
Results: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs.
Conclusions: Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs
Epidemiology, Practice of Ventilation and Outcome for Patients at Increased risk of Postoperative Pulmonary Complications: Las Vegas - an Observational Study in 29 Countries
BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients.
OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs.
DESIGN This was a prospective international 1-week observational study using the āAssess Respiratory Risk in Surgical Patients in Catalonia risk scoreā (ARISCAT score) for PPC for risk stratification.
PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries.
MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes.
RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure.
CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome