COVID-19 in Intensive Care Units

Klinički se virus prezentira od vrlo blagih simptoma, blage prehlade pa sve do pneumonije koja može dovesti do akutnoga respiratornog zatajenja i u kasnijoj fazi multiorganskog zatajivanja sa smrtnošću od 2 do 10 %. Kod hospitaliziranih bolesnika intersticijska upala pluća i ARDS javljaju se obično tijekom drugog tjedna liječenja, 7 − 9 dana od početka bolesti. Neinvazivna ventilacijska potpora nije se pokazala učinkovitom u liječenju ovog tipa ARDS-a uz postojeći dodatni rizik od pojačanog širenja bolesti na medicinsko osoblje (otvoreni sustav ventilacije), a odgađanje invazivne ventilacijske potpore često dovodi do pogoršanja stanja bolesnika. Bolesnici sa saturacijom 75 − 80 % i PaO2/FiO2 < 150 zahtijevaju invazivno ventilacijsko liječenje. Kod ovih bolesnika može se javiti fulminantna kardiomiopatija čak i u stadijima oporavka od bolesti. Još nije jasno izaziva li infekcija virusnu kardiomiopatiju ili je srčana disfunkcija posljedica citokinske oluje. Pravovremeno odvajanje od mehaničke ventilacije ključni je dio uspješnog liječenja COVID-19 bolesnika iz razloga što je uopće respiratorna potpora bila u većini slučajeva granično indicirana. Produženom ventilacijom bolesnika, dužom od 5 do 7 dana stvaraju se uvjeti za naseljavanje drugih patogena počesto rezistentnih bakterija i gljivica koje nailaze na izrazito oslabljen imunološki odgovor domaćina čime je put prema sepsi značajno skraćen i ubrzan. Za kontroliranje i uspješno liječenje najtežih COVID-19 respiratornih infekcija važna je dobra organizacija jedinica intenzivnog liječenja uz jasno definirane protokole. U takvoj jedinici mora raditi dovoljan broj medicinskog osoblja, prvenstveno najiskusniji liječnici intenzivisti, medicinski tehničari koji su ujedno i najvažnije osoblje.The virus develops from very mild symptoms, mild colds, to pneumonia that can lead to acute respiratory failure and ultimately to multiorgan failure with a mortality of 2 to 10%. In hospitalized patients, interstitial pneumonia and ARDS usually occur during the second week of treatment, 7 – 9 days from the onset of the disease. Non-invasive ventilation support has not been shown to be effective in treating this type of ARDS with the existing additional risk of increased disease spread to medical staff (open ventilation system). But delaying invasive ventilation support often leads to worsening of the patient\u27s condition. Patients with a saturation of 75 – 80% and PaO2 / FiO2 <150 require invasive ventilation treatment. Fulminant cardiomyopathy may occur in these patients even in the stages of recovery from the disease. It is not yet clear whether the infection causes viral cardiomyopathy or whether cardiac dysfunction is due to a cytokine storm. Early weaning from mechanical ventilation is one of the key aspects of successful treatment of patients with COVID-19 because respiratory support in general was borderline indicated in most cases. Prolonged ventilation of patients for more than 5 – 7 days creates conditions for the colonization of other pathogens, often resistant bacteria and fungi that encounter a markedly weakened immune response of the host, which significantly shortens and accelerates the path to sepsis. Good organization of intensive care units with clearly defined protocols is important for the control and successful treatment of the most severe COVID-19 respiratory infections. Such units must have a sufficient number of medical staff, primarily meaning the most experienced intensive care physicians, and medical technicians who are essentially the most important personnel

COVID-19 in Intensive Care Units

Klinički se virus prezentira od vrlo blagih simptoma, blage prehlade pa sve do pneumonije koja može dovesti do akutnoga respiratornog zatajenja i u kasnijoj fazi multiorganskog zatajivanja sa smrtnošću od 2 do 10 %. Kod hospitaliziranih bolesnika intersticijska upala pluća i ARDS javljaju se obično tijekom drugog tjedna liječenja, 7 − 9 dana od početka bolesti. Neinvazivna ventilacijska potpora nije se pokazala učinkovitom u liječenju ovog tipa ARDS-a uz postojeći dodatni rizik od pojačanog širenja bolesti na medicinsko osoblje (otvoreni sustav ventilacije), a odgađanje invazivne ventilacijske potpore često dovodi do pogoršanja stanja bolesnika. Bolesnici sa saturacijom 75 − 80 % i PaO2/FiO2 < 150 zahtijevaju invazivno ventilacijsko liječenje. Kod ovih bolesnika može se javiti fulminantna kardiomiopatija čak i u stadijima oporavka od bolesti. Još nije jasno izaziva li infekcija virusnu kardiomiopatiju ili je srčana disfunkcija posljedica citokinske oluje. Pravovremeno odvajanje od mehaničke ventilacije ključni je dio uspješnog liječenja COVID-19 bolesnika iz razloga što je uopće respiratorna potpora bila u većini slučajeva granično indicirana. Produženom ventilacijom bolesnika, dužom od 5 do 7 dana stvaraju se uvjeti za naseljavanje drugih patogena počesto rezistentnih bakterija i gljivica koje nailaze na izrazito oslabljen imunološki odgovor domaćina čime je put prema sepsi značajno skraćen i ubrzan. Za kontroliranje i uspješno liječenje najtežih COVID-19 respiratornih infekcija važna je dobra organizacija jedinica intenzivnog liječenja uz jasno definirane protokole. U takvoj jedinici mora raditi dovoljan broj medicinskog osoblja, prvenstveno najiskusniji liječnici intenzivisti, medicinski tehničari koji su ujedno i najvažnije osoblje.The virus develops from very mild symptoms, mild colds, to pneumonia that can lead to acute respiratory failure and ultimately to multiorgan failure with a mortality of 2 to 10%. In hospitalized patients, interstitial pneumonia and ARDS usually occur during the second week of treatment, 7 – 9 days from the onset of the disease. Non-invasive ventilation support has not been shown to be effective in treating this type of ARDS with the existing additional risk of increased disease spread to medical staff (open ventilation system). But delaying invasive ventilation support often leads to worsening of the patient\u27s condition. Patients with a saturation of 75 – 80% and PaO2 / FiO2 <150 require invasive ventilation treatment. Fulminant cardiomyopathy may occur in these patients even in the stages of recovery from the disease. It is not yet clear whether the infection causes viral cardiomyopathy or whether cardiac dysfunction is due to a cytokine storm. Early weaning from mechanical ventilation is one of the key aspects of successful treatment of patients with COVID-19 because respiratory support in general was borderline indicated in most cases. Prolonged ventilation of patients for more than 5 – 7 days creates conditions for the colonization of other pathogens, often resistant bacteria and fungi that encounter a markedly weakened immune response of the host, which significantly shortens and accelerates the path to sepsis. Good organization of intensive care units with clearly defined protocols is important for the control and successful treatment of the most severe COVID-19 respiratory infections. Such units must have a sufficient number of medical staff, primarily meaning the most experienced intensive care physicians, and medical technicians who are essentially the most important personnel

Utjecaj prijeoperacijskog hranjenja na motilitet želuca, peristaltiku tankog crijeva i veličinu žučnog mjehura tijekom ranog poslijeoperacijskog perioda u bolesnika operiranih u spinalnoj anesteziji : doktorski rad

CILJ: ispitati utjecaj prijeoperacijskog hranjenja na brzinu pražnjenja želuca, na peristaltiku tankog crijeva i na veličinu žučnog mjehura u ranom poslijeoperacijskom razdoblju u bolesnika predviđenih za ortopedski zahvat u spinalnoj anesteziji. Uspoređivala se i dužina trajanja hospitalizacije u prijeoperacijski hranjenih u odnosu na nehranjene bolesnike. ISPITANICI I METODE: u studiju je uključeno 120 bolesnika s odjela traumatologije. Bolesnici predviđeni za operacijski zahvat ugradnje parcijalne proteze zgloba kuka u spinalnoj anesteziji, bili su klasificirani kao ASA II i ASA III (anesteziološki bodovni sustav klasifikacije komorbiditeta bolesnika prije operacijskog zahvata) i randomizirani u dvije skupine. Ispitanici skupine 1 (60 bolesnika) bili su hranjeni pripravkom bistre tekućine obogaćene ugljikohidratima (PreOp 200 ml) dva sata prije operacije, dok se u ispitanika kontrolne skupine (skupina 2; 60 bolesnika) provodio dosadašnji standardizirani protokol prijeoperacijskog noćnog gladovanja. Paracetamolski test apsorpcije primjenio se u svih ispitanika uključenih u studiju, kao indirektni pokazatelj brzine pražnjenja želuca. Svim je ispitanicima poslijeoperacijski učinjen ultrazvuk abdomena kojim se promatralo prisustvo ili odsustvo peristaltike tankog crijeva te se mjerila veličina žučnog mjehura. REZULTATI: uspoređujući obje skupine ispitanika nema statistički značajne razlike u koncentraciji paracetamola u plazmi tijekom prvih 120 minuta. Peristaltika tankog crijeva statistički je značajno bolja u prijeoperacijski hranjenih bolesnika. Veličina žučnog mjehura u ranom poslijeoperacijskom razdoblju manja je u prijeoperacijski hranjenih bolesnika. Dužina boravka u bolnici statistički je značajno kraća u skupini 1 u odnosu na skupinu 2: 12 (9-19) dana prema 16 (11-22) dana; p<0,001. ZAKLJUČCI: Hranjenje bolesnika, predviđenih za ugradnju parcijalne endoproteze zgloba kuka u spinalnoj anesteziji, dva sata prije operacije bistrom tekućinom obogaćenom ugljikohidratima nema utjecaja na pražnjenje želuca u ranom poslijeoperacijskom razdoblju ali značajno poboljšava peristaltiku tankog crijeva, smanjuje veličinu odnosno potiče rad žučnog mjehura te skraćuje boravak bolesnika u bolnici.OBJECTIVES: to investigate influence of the preoperative feeding on gastric emptying, small bowel peristaltic and gall bladder contractility early after the orthopaedic surgery in spinal anesthesia. Comparison of the length of stay in hospital were made between same two groups. MATERIAL AND METHODS: 120 patients from Department of Traumatology were included in this study. They were randomized in two groups and classified as ASA II and III for the implantation of endoprosthesis of the hip joint in spinal anesthesia. Patients from the group 1 (60 patients) consumed clear carbohydrate enriched drink (PreOp 200 ml) two hours before surgery. Group 2 (60 patients) represent the patients who overnight fasted. The paracetamol test was performed on all patients in the study, as the indirect demonstration of the gastric emptying rate. Abdominal ultrasound was performed in all patients whereby the peristaltic of the small bowel was observed as well as gall bladder size. RESULTS: there are no statistical significance was observed among the two groups in paracetamol plasma concentrations during the early postoperative period. Peristaltic of the small bowel in the early postoperative period was significantly better in preoperativly feeded patients and same group showed reduction of the gall bladder size and volumen in comparson with control group. The length of stay in hospital was significantly shorter for the group 1 comparison with group 2: 12 (9-19) days vs. 16 (11-22) days; p<0,001. CONCLUSIONS: The preoperative feeding of the patients in spinal anesthesia two hours before surgery has no influence on gastric emptying rate in early postoperative period but significantly enhance the peristaltic of the small bowel, reduce size and volumen of the gall bladder and shortens length of stay in hospital

Educational polygon „Skills lab”

Simulatori i simulacija postali su sastavni i nezamjenjiv dio medicinske edukacije i istraživanja. U većini medicinskih učilišta Zapadne Europe i SAD-a postoje specijalizirane učionice za učenje određenih medicinskih vještina pomoću simulatora i simulacije, koje se ne mogu u potpunosti savladati tijekom boravka na odgovarajućim odjelima, odnosno za vrijeme kliničke nastave. Jedan od zasigurno najvažnijih segmenta u edukaciji studenata medicine i drugih zdravstvenih grana je kardiopulmonalna reanimacija. Zbog specifične važnosti i nemogućnosti učenja ovih postupaka na bolesnicima, neophodno je omogućiti studentima i polaznicima tečajeva oživljavanja uvježbavanje navedenih postupaka na sofisticiranim modelima (tzv. „lutke ili modeli”) u prostoru ili učionici isključivo namijenjenima toj namjeni. Takav edukacijski poligon za uvježbavanje postupaka kardiopulmonalnog oživljavanja (CPR) ustrojen je 2001. godine pod imenom „Kabinet vještina„. Danas u svijetu postoji sve veća potreba za ovakvim centrima edukacije koji uključuju prilagodbu i potrebama „medicinskih laika„, tj. nemedicinskog osoblja, kako bi se educirao širok krug koji će biti u mogućnosti pružiti prvu i potrebnu pomoć na samom mjestu događaja.Simulators and simulations have become an integral and indispensable part of medical education and research. Specialized educational polygons for training of certain medical skills using simulators and simulations, which cannot be fully mastered during stay at clinical departments or during clinical teaching, exist in most medical schools and university hospitals in Western Europe and USA. One of the most important segments in the education of medical students and other health care professionals is cardiopulmonary resuscitation (CPR). Because of specific importance and inability to learn CPR procedures on patients, it is necessary to enable students and course trainees education on sophisticated models (called „dolls or models”) in classroom exclusively created for this purpose. Such educational polygon, for training of cardiopulmonary resuscitation procedures, was established in 2001. In Rijeka and was named „Skills lab”. Today in the world there is an increasing need for simulation training centers that are maximally equipped and adapted for education of non-medical staff („medical-laics”) with a goal to educate people to be able to provide a first and necessary assistance in CPR at the scene of event

Primjena veno-venske izvantjelesne membranske oksigenacije kod pacijenata s limfomom i teškim akutnim respiratornim distresnim sindromom: serija slučajeva

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.Cilj: Prikazati klinički tijek dvoje pacijenata, pacijenta s Hodgkinovim limfomom i pacijentice s ne-Hodgkinovim limfomom, koji su razvili teški refraktorni akutni respiratoracijski distresni sindrom (engl. acute respiratory distress syndrome; ARDS) te su liječeni veno-venskom izvantjelesnom membranskom oksigenacijom (engl. veno-venous extracorporeal membrane oxygenation; VV ECMO). Prikaz slučaja: Nakon kemoterapije pacijenti su razvili febrilnu neutropeniju, pneumoniju i ARDS, nakon čega su premješteni u jedinicu intenzivnog liječenja. Unatoč orotrahealnoj intubaciji i protektivnoj mehaničkoj ventilacijskoj potpori, došlo je do pogoršanja njihova respiracijskog statusa te se odlučilo uvesti VV ECMO potporu. Imali su kompliciran klinički tijek praćen teškim komplikacijama povezanim s korištenjem ECMO-a. Kod pacijenta s Hodgkinovim limfomom razvile su se sljedeće komplikacije: kardijalni arest; laceracija aurikule desnog atrija s tamponadom perikarda, što je zahtijevalo kirurško liječenje; ishemija desne noge koja je zahtijevala transfemoralnu amputaciju; tromboza membranskog oksigenatora; nekoliko septičkih epizoda praćenih teškom hemodinamskom nestabilnošću te desnostrani tenzijski pneumotoraks. Iako se uspješno odvaja od ECMO-a, pacijent je preminuo na odjelu zbog sepse s multiorganskim zatajenjem. U pacijentice s ne-Hodgkinovim limfomom razvilo se difuzno orofaringealno i kontinuirano obostrano plućno krvarenje; sekundarna bakterijska pneumonija; opsežan pneumomedijastinum i subkutani emfizem. Unatoč svim mjerama potpore, pacijentica je preminula tokom liječenja ECMO-om zbog dekompenzacije respiracijskog zatajivanja. Zaključak: Pacijenti s hematološkim neoplazmama liječeni ECMO-om imaju loše terapijske ishode praćene čestim i teškim komplikacijama. Potrebna su klinička istraživanja s posebnom pažnjom na izbor pacijenata, prevenciju, dijagnozu i liječenje komplikacija povezanih s korištenjem ECMO-a

Educational polygon „Skills lab”

Simulatori i simulacija postali su sastavni i nezamjenjiv dio medicinske edukacije i istraživanja. U većini medicinskih učilišta Zapadne Europe i SAD-a postoje specijalizirane učionice za učenje određenih medicinskih vještina pomoću simulatora i simulacije, koje se ne mogu u potpunosti savladati tijekom boravka na odgovarajućim odjelima, odnosno za vrijeme kliničke nastave. Jedan od zasigurno najvažnijih segmenta u edukaciji studenata medicine i drugih zdravstvenih grana je kardiopulmonalna reanimacija. Zbog specifične važnosti i nemogućnosti učenja ovih postupaka na bolesnicima, neophodno je omogućiti studentima i polaznicima tečajeva oživljavanja uvježbavanje navedenih postupaka na sofisticiranim modelima (tzv. „lutke ili modeli”) u prostoru ili učionici isključivo namijenjenima toj namjeni. Takav edukacijski poligon za uvježbavanje postupaka kardiopulmonalnog oživljavanja (CPR) ustrojen je 2001. godine pod imenom „Kabinet vještina„. Danas u svijetu postoji sve veća potreba za ovakvim centrima edukacije koji uključuju prilagodbu i potrebama „medicinskih laika„, tj. nemedicinskog osoblja, kako bi se educirao širok krug koji će biti u mogućnosti pružiti prvu i potrebnu pomoć na samom mjestu događaja.Simulators and simulations have become an integral and indispensable part of medical education and research. Specialized educational polygons for training of certain medical skills using simulators and simulations, which cannot be fully mastered during stay at clinical departments or during clinical teaching, exist in most medical schools and university hospitals in Western Europe and USA. One of the most important segments in the education of medical students and other health care professionals is cardiopulmonary resuscitation (CPR). Because of specific importance and inability to learn CPR procedures on patients, it is necessary to enable students and course trainees education on sophisticated models (called „dolls or models”) in classroom exclusively created for this purpose. Such educational polygon, for training of cardiopulmonary resuscitation procedures, was established in 2001. In Rijeka and was named „Skills lab”. Today in the world there is an increasing need for simulation training centers that are maximally equipped and adapted for education of non-medical staff („medical-laics”) with a goal to educate people to be able to provide a first and necessary assistance in CPR at the scene of event

Minimally invasive ultrasound guided surgery for extracting stitches as a cause of secondary infections after tendoraphy of the Achilles tendon rupture

Cilj: Prikazati mogućnosti korištenja ultrazvuka u rješavanju kasnih komplikacija nakon kirurškog zbrinjavanja rupturirane Ahilove tetive. Prikaz slučaja: U radu su prikazana dva bolesnika kod kojih se nakon šest i pet godina na mjestu kirurške intervencije zbog rupture Ahilove tetive razvio upalni proces uz formiranje apscesa. Ultrazvučnim pregledom se u oba bolesnika dijagnosticira postojanje apscesa i stranog tijela u smislu zaostalog konca. Pod kontrolom ultrazvuka u operacijskoj dvorani minimalno invazivnim kirurškim pristupom izvade se svi zaostali konci i drenira formirani apsces. Rasprava: Klasični kirurški zahvat je invazivan s mogućnošću propagacije infekcije prema zdravom tkivu te uz mogućnost pogreške u smislu nenalaženja svih zaostalih konaca uzročnika upalnog odgovora. Prikazom ovih dvaju slučajeva dokazali smo da, osim u dijagnostičke svrhe, ultrazvuk može poslužiti kao pomoć pri samom kirurškom postupku u cilju izvođenja minimalno invazivnog kirurškog zahvata. Zaključak: U prikazu slučaja upućuje se na potencijalnu vrijednost minimalno invazivne kirurške tehnike pod kontrolom ultrazvuka kojom se mogu izvaditi zaostali konci i drenirati nastali apsces u bolesnika.Aim: To evaluate the use of ultrasound in management of the long term complications after surgical procedure of the ruptured Achiles tendon. Case report: Authors report two cases of patients who developed tissue inflammation and abscess six and five years after surgery following rupture of the Achilles tendon. Ultrasound examination of the Achilles tendon confirmed abscess and foreign body (stitch) in both patients. A minimally invasive ultrasound guided technique was used for extracting all stitches and drainage of the present abscess in both patients. Discussion: The clasical surgical approach is an invasive procedure with high possibility of widespreading infection into the healthy tissue. There is also the possibility of not finding all stitches which cause inflammation. These two cases emphasize the use of ultrasound not only for diagnosis but also as a help, during the minimally invasive surgical procedure. Conclusion: In this case report we point out the potential value of the minimally invasive ultrasound guided surgery for extracting stitches and drainage of the present abscesses in both patients

A brief reeducation in cardio-pulmonary resuscitation after six months-the benefit from timely repetition

Objectives. Sudden cardiac death is a major cause of death in today\u27s world. During the minutes passing from the onset of cardiac arrest to the arrival of professional help, the cardiac arrest victim can only rely upon cardio-pulmonary resuscitation (CPR) provided by educated bystanders. Our aim was to explore the possibility of whether a short and affordable course of CPR reeducation could have a significant effect on skills retention and quality of CPR delivered. Methods. We performed a prospective randomized study that included 72 first and second year medical students who had no clinical experience and no prior training in CPR. Subjects were educated in CPR in accordance with a standardized CPR education protocol. Six months later, half of the studied group (randomly chosen) underwent short reeducation in CPR. One year after initial education they were all tested for CPR skills. The results were printed and filmed. Results. Students who attended the short reeducation were significantly better in approaching the victim safely, in obtaining a clear airway and in checking the pulse of the victim. Conclusions. A short and inexpensive course of reeducation, carried out six months after initial education, may render CPR performance more effective for the victim and safer for the rescuer