Plućni žilni permeabilni indeks i izvanžilna plućna tekućina u bolesnika sa sepsom [Pulmonary vascular permeability index and extravascular lung water in patients with sepsis]

It is possible to measure pulmonary vascular permeability index (PVPI) and extravascular lung water (EVLW) with PiCCO (Pulse-induced Contour Cardiac Output) monitoring. Hypothesis of the study was: due to the toxic impairment of alveolocapillary membrane, patients with sepsis syndrome suffer of reduced pulmonary complinace and have higher PVPI and EVLW values. Aim of our study was to investigate PVPI and EVLW values and dynamics in development of pulmonary oedema in sepsis syndrome, identify possible differences in measured values, as well as determine their correlation with other investigated parameters. Investigated group included 50 patients, after urgent abdominal surgery, with clinically and laboratoy confirmed sepsis, and mild ARDS (ARDS - acute respiratory distress syndrome) according to Berlin definition. Control group included 50 patients without mild ARDS. All patients were intubated and mechanically ventilated. PVPI and EVLW measurements were taken in both study groups three times a day. Values of P<0,05 were considered statistically significant. Study results showed statistically significant difference of PVPI and EVLW in investigated compared to control group. In conclusion, PVPI and EVLW can be used in the early diagnosis and dynamics of mild ARDS in surgical patients with sepsis

Intermediate cervical plexus block for carotid endarterectomy in high risk patients

Background and Purpose: Regional anesthesia is the choice for patients undergoing preventive open carotid surgery. Recently intermediate cervical plexus block has been described as a reliable and safe anesthesia technique in comparison with superficial and deep cervical plexus block. The aim of our study was to assess the complications of intermediate cervical plexus block in high risk patients. Materials and Method: The study was performed in 29 ASA III and ASA IV patients with the intermediate cervical plexus block for carotid endarterectomy from January 2006 till November 2008 in the University Hospital Zagreb. The following data were collected: age, sex, ASA status and preoperative disease. Furthermore, intraoperative and postoperative complications associated with intermediate cervical plexus block and carotid endarterectomy were recorded. Results: Median age was 69 years (range, 46 – 82 years). One patient developed Horner’s syndrome, three patients developed transitory ischemic attack, one developed stroke intraoperatively and died, seven patients developed transitory hemodynamic instability, one was hypotensive in the postoperative period and required vasoactive support. Conclusion: Intermediate cervical plexus block is safe and effective for carotid endarterectomy in high risk patients

Extravascular lung water index as an indicator of lung injury in septic patients

Introduction. Transpulmonary thermodilution using PiCCO (Pulse-induced Contour Cardiac Output) is a standard minimally invasive method used for haemodynamic monitoring. Objectives. The goal of this paper is to examine the correlation and dynamics of the ExtraVascular Lung Water Index (EVLWI) as an indicator of acute lung injury in septic patients who underwent major abdominal surgery. Two groups of patients were selected: the ones with ALI (Acute Lung Injury): ALI patient group, and the ones without ALI: non-ALI patient group. A correlation between EVLWI and other haemodynamic and respiratory data in both groups were analyzed. Materials and methods. The study included 48 patients. Throughout the seven-day period EVLWI, GEDVI (Global End-Diastolic Volume Index), ITBVI (IntraThoracic Blood Volume Index), CI (Cardiac Index), SVRI (Systemic Vascular Resistance Index) were measured in both groups using PiCCO monitoring over 8-hour intervals as well as heart rate, mean arterial pressure, serum albumin concentration, PaCO2 (arterial partial pressure of carbon dioxide), PaO2 (arterial partial pressure of oxygen), PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio, lung compliance, lung resistance and ScvO2 (central venous oxygen saturation). All patients were analgosedated, intubated, mechanically ventilated, in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and Sequential Organ Failure Assessment (SOFA) scores calculated. Ventilator settings and dosage of vasoactive drugs were kept constant during the study. Results. EVLWI was significantly higher in ALI patients group compared to non-ALI patients group. In patients with ALI group 11/22 patients died (50%), in the non-ALI patients group 6/26 patients died (23%). EVLWI was significantly higher in patients that died compared to ones who survived. Conclusion. EVLWI is a good indicator of early acute lung injury in surgical patients with sepsis

Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

Intra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients was analysed. Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk factors for IAH. Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley catheter placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05 was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg. Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus 1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients). Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group. Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with consequent multi-organ failure, and for timely application of efficacious therapeutic procedures

Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

Intra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients was analysed. Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk factors for IAH. Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley catheter placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05 was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg. Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus 1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients). Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group. Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with consequent multi-organ failure, and for timely application of efficacious therapeutic procedures

HES solutions in critical illness, trauma and perioperative period

In the last few years, many studies and meta-analyses have demonstrated that hydroxyethyl starch (HES) solutions increase the risk of acute renal failure and mortality in critically ill patients. Some studies suggest complete avoidance of HES solutions in patients of all categories. On the other hand, recent studies and analyses suggest that HES solutions may be used in hypovolemic critically ill patients and in the perioperative setting. The main problem in everyday clinical practice and in a rational fluid management approach is that treatment with alternatives to HES solutions is not always pathophysiologically justified (crystalloids) or confirmed in randomised controlled trials (gelatins, albumins)

Regional anesthesia for trauma patients

Trauma patients demands special medical care. Pain is frequently undertreated in the early phase of trauma. Pain is a major symptom of surgical conditions and minimizing pain could lead to misdiagnoses and technical facilities are not appropriate for adequate pain treatment. Consequences of inappropriate pain treatment could aggravate stress response, increases oxygen demand and led to myocardial ischemia Analgesia with parenteral opioids is effective but carries a risk of respiratory depression, nausea and hypotension. Regional anesthesia (RA) is well established method for analgesia in surgical patients for intraoperative and postoperative pain relief. Neuroaxial and peripheral nerve blocks are effective procedures for acute pain treatment. Nerve stimulation and advances in ultrasound guide nerve blocks make those procedures safer and even more desirable. Advantages of RA over systemic analgesia in trauma patients are numerous. Application of local anesthetics produce excellent pain control with decreased stress response and minimal systemic effects is applied properly. Main indications for RA include patients with rib fractures and lower and upper extremities injuries. Anesthesiologist performing RAmust be aware of pathophysiology changes in trauma patients especially addressing compartment syndrome and coagulation abnormalities. Best way is to weighed risk against the benefit of RA in trauma patients individually with increased vigilance and monitoring for eventual side effects

Regionalna anestezija u neurokirurgiji

During neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery.Tijekom neurokirurših zahvata u bolesnika je vrlo bitno osigurati optimalnu cerebralnu perfuziju i oksigenaciju. Unatoč fiziološkoj autoregulaciji perfuzije mozga, održavanje hemodinamske stabilnosti i dobre oksigenacije tijekom anestezije od vitalnog je značaja za uspjeh. Opća anestezija s mehaničkom ventilacijom i suvremenim anesteticima omogućuje zadovoljavajuću hemodinamsku stabilnost i prvi je izbor za većinu neurokirurških zahvata. Međutim, ponekad je vrlo teško izbjeći kratke varijacije krvnog tlaka tijekom jakih i slabih bolnih podražaja koji se izmjenjuju tijekom zahvata. Promjene sistemnog arterijskog tlaka mogu biti štetne za bolesnike s visokim intrakranijskim tlakom i edemom mozga. Liječenje se sastoji u prilagodbi dubine anestezije ili primjene vazoaktivnih lijekova. S druge strane bolesnika je važno brzo probuditi nakon anestezije za neurološki pregled. Regionalna anestezija glave i kralježnice može pokazati povoljan učinak smanjenja bolnog podražaja i hemodinamske varijabilnosti uz uštedu doza anestetika. Također regionalne tehnike pružaju odličano ublažavanje postoperativne boli

Transfusion in polytraumatised patients

Background and Aim. Recent evidence indicates that surgical bleeding due to injured vessels and traumatic coagulopathy are the main reasons of uncontrolled haemorrhage in polytraumatized patients in the first 24 hours. The cornerstone of the treatment is adequate empiric early transfusion. The aim of our study was to survey the early transfusion in patients with major trauma and define the ratio of applied transfusion component in our hospital. Patients and Methods: Patients with major trauma for a one year period, admitted to the Emergency Department of the Clinical Hospital Centre, Zagreb, were enrolled in our retrospective study. The following data were collected: age, sex, mechanism of injury, initial shock index (SI), initial Glasgow Coma Score (GCS), Injury severity score (ISS), and initial hemoglobin (Hb) and prothrombin time (PT). Intra-operative transfusion and transfusion within the first 24 hours of injury, Intensive care unit (ICU) stay and clinical outcome were assessed. Results. 16 patients with major trauma were admitted. Eight patients received transfusions. Two patients received a massive transfusion. The transfusion ratio of Fresh frozen plasma (FFP) : Packed red blood cells (PRBC) : Platelets (PLT) during major trauma resuscitation was 1:1,5:1 in our study. One of the 16 patients died. Conclusion. Early and aggressive resuscitation with transfusion blood products in major trauma patients within the first 24 hours with the FFP:PRBC:PLT ratio 1:1:1 is the key for prevention of trauma induced coagulopathy and its lethal consequences. Massive transfusion protocol for major trauma patients should be implemented in everyday practice

Effects of the mechanical ventilation on the cardiovascular system

Mechanical ventilation with positive pressure significantly influences cardiovascular system function. The main effects are a decrease of right ventricular preload and a decrease of left ventricular afterload. The initiation of mechanical ventilation in cases of hypovolemia with right ventricular dysfunction or severe lung disease adversely affects the cardiovascular system. Mechanical ventilation has beneficial effects on cardiovascular function in patients with left ventricular dysfunction and increased preload, afterload, oxygen consumption and metabolic disarrangements