Dijagnostičko-terapijski pristup kompleksnoj koagulopatiji uslijed recidivirajućeg krvarenja iz mokraćnog 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.Poremećaji koagulacije kod bolesnika u jedinici intenzivnog liječenja (JIL) su često složeni. Farmakoterapija tijekom bolesti može poremetiti fiziološki proces zgrušavanja krvi. Dodatni koagulacijski testovi uz standardni dijagnostički pristup kod nastale refraktorne koagulopatije omogućuju ciljano terapijsko djelovanje i postizanje hemostaze. Bolesnik u dobi od 73 godine u JIL se prezentirao masivnim krvarenjem iz mokraćnog mjehura nakon litotripsije i uvođenja terapijske doze niskomolekularnog heparina zbog akutne plućne embolije. Podvrgnut je višestrukim pokušajima kirurške hemostaze i masivnom transfuzijskom protokolu koji nisu doveli do prestanka krvarenja. Standardni koagulacijski testovi nisu ukazivali na poremećaj hemostaze. Dodatnim testovima utvrđena je disfunkcija cirkulirajućih trombocita. Nakon isključivanja lijekova koji mogu utjecati na njihovu funkciju došlo je do oporavka trombocitne funkcije i postizanja hemostaze. Koagulacijski poremećaji kod bolesnika u JIL-u su multifaktorski. Polipragmazija kod teško oboljelih može utjecati na fiziološki proces zgrušavanja krvi. Standardni koagulacijski testovi su nedovoljno pouzdani za razrješavanje kompleksnih koagulopatija. Sveobuhvatni klinički 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 Kliničkog bolničkog centra Osijek o kraju života u jedinicama intenzivnog liječenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje se sastojalo od dva dijela: provođenje anonimne ankete među liječnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolničkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da većina liječnika nije primjenjivala smjernice za unaprijeđenje palijativne skrbi u JIL-u te da postoje dileme oko etičnosti ograničenja mjera umjetnog održavanja života. Kao glavni razlozi neprovođenja smjernica bili su identificirani nedostatak pravne zaštite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je značajno velik broj smrti nakon neuspješne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovođenju KPR-a i izostavljanju određene mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograničavanju mjera i postupaka umjetnog održavanja života, većina liječnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. Zaključak: Navedeni rezultati ukazuju na potrebu za poboljšanjem postupanja u donošenju 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 colleagues’ and families’ 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 liječenja posljednjih godina imaju sve veću ulogu pri zbrinjavanju bolesnika u jedinicama intenzivnog liječenja. Prednosti koje one pružaju u odnosu prema konvencionalnim, intermitentnim metodama pogoduju kritično oboljelima, zbog čega je ova metoda vrlo privlačna pri izboru terapijskog pristupa u jedinicama intenzivnog liječenja. Primjer je klinički prikaz dotad zdravoga četrdesetšestogodišnjeg muškarca koji je primljen u jedinicu intenzivnog liječenja zbog iznenadno nastalog poremećaja stanja svijesti, respiratorne insuficijencije, cirkulacijske nestabilnosti, rabdomiolize, anurije i akutnoga bubrežnog oštećenja nepoznatog uzroka. Bolesnik je mehanički ventiliran, volumno resuscitiran, nalažući cirkulacijsku potporu vazopresorima. Unatoč inicijalno poduzetim mjerama intenzivnog liječenja nije došlo do oporavka diureze i hemodinamske stabilizacije uz daljnje pogoršanje stanja. Zbog perzistirajuće hiperkalemije opasne za život, metaboličke acidoze, uremije i rabdomiolize započeti su kontinuirano bubrežno nadomjesno liječenje (engl. Continuous renal replacement therapy – CRRT), uz istodobno pružanje potpore narušenim organskim sustavima, i traganje za mogućim uzrokom prezentirane kliničke slike. Nakon tjedan dana kontinuirane potpore narušenoj bubrežnoj funkciji došlo je do oporavka stanja svijesti, hemodinamske stabilizacije, odvajanja od strojne ventilacije i oporavka diureze uz normalizaciju bubrežne funkcije. Ciljanom toksikološkom analizom urina potvrđeno je da su anabolički steroidi koje je bolesnik uzimao mogući uzrok rabdomiolize i bubrežnog oštećenja. Bolesnik je desetog dana otpušten iz jedinice intenzivnog liječenja u dobrom općem stanju i uredne bubrežne funkcije. Kontinuirane metode bubrežnoga nadomjesnog liječenja učinkovit su način zbrinjavanja akutnoga bubrežnog oštećenja u kritično oboljelih zbog nastaloga multiorganskog zatajenja različite 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 46–year-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 očituje se malapsorpcijom koja je posljedica opsežne resekcije crijeva. Duljina crijeva preostaloga nakon kirurške resekcije smatra se glavnom odrednicom ishoda u tih bolesnika. Liječenje sindroma složeno je i nalaže multidisciplinarni pristup radi smanjenja morbiditeta i mortaliteta. Ovaj prikaz opisuje 60-godišnju bolesnicu koja je podvrgnuta multiplim resekcijama crijeva, što je rezultiralo preostalim tankim crijevom duljine 30 cm postduodenalno i terminalnom jejunostomom. Njezin boravak u jedinici intenzivnog liječenja zakomplicirao se zbog razvoja respiratornog zatajenja, bilateralne pneumonije i sepse. Pacijentica je mehanički ventilirana i liječena antimikrobnim lijekovima u skladu s rezultatima mikrobioloških pretraga i antibiogramom. Inicijalno je započeta potpuna parenteralna prehrana, dok se enteralna prehrana uvodila postupno. U liječenju bolesnice sudjelovao je multidisciplinarni tim sastavljen od anesteziologa, kirurga i gastroenterologa. Nakon četiri mjeseca bolničkog liječenja pacijentica je otpuštena kući opremljena tuneliranim središnjim venskim kateterom, a parenteralna je prehrana nastavljena u kućnim 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 donošenje odluka o kraju života u intenzivnoj medicini?

Cilj istraživanja: Usporediti stavove intenzivista Kliničkog bolničkog centra Osijek o kraju života u jedinicama intenzivnog liječenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje se sastojalo od dva dijela: provođenje anonimne ankete među liječnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolničkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da većina liječnika nije primjenjivala smjernice za unaprijeđenje palijativne skrbi u JIL-u te da postoje dileme oko etičnosti ograničenja mjera umjetnog održavanja života. Kao glavni razlozi neprovođenja smjernica bili su identificirani nedostatak pravne zaštite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je značajno velik broj smrti nakon neuspješne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovođenju KPR-a i izostavljanju određene mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograničavanju mjera i postupaka umjetnog održavanja života, većina liječnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. Zaključak: Navedeni rezultati ukazuju na potrebu za poboljšanjem postupanja u donošenju odluka o kraju života u JIL-u

Poslijeoperacijska sustavna upala nakon velike abdominalne operacije ne mijenja analgetski učinak 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 često rabi za poslijeoperacijsku bol u jedinicama intenzivnog liječenja (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 učinku tramadola kod bolesnika ovisno o razvoju sustavne upale. Četrdesettroje 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 numeričke ocjenske ljestvice (NRS) rađena 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 sljedećih kriterija: vrućica 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 značajno 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 statistički značajna. Statistički značajna negativna korelacija zabilježena je između prijeoperacijskih vrijednosti CRP-a i PCT-a i analgetskog učinka tramadola u drugoj mjernoj točki (r=-0,358, p=0,03 i r=-0,364, p=0,02). Katehol-O-metiltransferaza nije povezana s potrošnjom analgetika niti jačinom boli. Rezultati ovog istraživanja pokazali su da je tramadol učinkovit 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 ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (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