Usporedba rane i kasne perkutane traheotomije u kritično bolesnih: retrospektivna opservacijska studija u jednom centru

Despite decades of experience in tracheotomy, there still exists a controversy over its ideal timing. The aim of our study was to compare the impact of early and late percutaneous tracheotomy in terms of their ability to reduce mechanical ventilation duration and length of stay in Intensive Care Unit, as well as the frequency of ventilator-associated pneumonia and mortality rates in tracheotomized patients. This retrospective observational study indicated that early tracheotomy in surgical and neurosurgical patients was associated with a reduced duration of mechanical ventilation and reduced length of stay in Intensive Care Unit, but was unable to reduce the frequency of ventilator-associated pneumonia and mortality. The reason behind the shorter duration of mechanical ventilation and shorter length of stay in Intensive Care Unit in the early tracheotomy arm was shorter duration of mechanical ventilation carried out prior to tracheotomy, while the duration of mechanical ventilation and the length of stay in Intensive Care Unit after tracheotomy were similar in both groups, suggesting that the procedure itself and not its timing influenced the duration of mechanical ventilation and the length of stay in Intensive Care Unit of tracheotomized patients.Traheotomija je vrlo čest postupak koji se izvodi kod bolesnika koji zahtijevaju produženu mehaničku ventilaciju. Unatoč desetljećima iskustva u izvođenju traheotomije još uvijek postoje dileme o idealnom vremenu izvođenja. Cilj ovoga istraživanja je bio usporedba rane i kasne traheotomije s obzirom na njihov utjecaj na trajanje mehaničke ventilacije i duljinu boravka u Jedinici intenzivnog liječenja, kao i na učestalost pojave ventilacijske pneumonije i smrtnost među traheotomiranim bolesnicima. Istraživanje je provedeno u 15-krevetnoj Jedinici intenzivnog liječenja Odjela za anesteziologiju, reanimatologiju i intenzivno liječenje u Kliničkom bolničkom centru “Sestre milosrdnice”, Zagreb, Hrvatska. Podaci su skupljani retrospektivno od rujna 2009. do ožujka 2013. godine. U istraživanje su bili uključeni samo bolesnici perkutano traheotomirani tijekom navedenog razdoblja. Rezultati ovoga istraživanja ukazuju na to da rana traheotomija skraćuje trajanje mehaničke ventilacije i duljinu boravka u Jedinici intezivnog liječenja, dok na učestalost ventilacijske pneumonije i smrtnost nema utjecaja. Razlog kraćeg trajanja mehaničke ventilacije i kraćeg boravka u Jedinici intezivnog liječenja je kraće trajanje mehaničke ventilacije prije izvođenja traheotomije, dok je trajanje mehaničke ventilacije nakon traheotomije bilo slično u obje skupine, što upućuje na zaključak da sam postupak traheotomije, a ne vrijeme izvođenja utječe na trajanje mehaničke ventilacije i duljinu boravka u Jedinici intenzivnog liječenja

Checklists as a standard of patient safety in the healthcare process

Kvalitetna zdravstvena skrb je osnovno pravo svakog pojedinca i kao takvo se spominje i u brojnim dokumentima koji se odnose na prava pacijenata te ljudska prava. Jedna od sastavnica kvalitete zdravstvene zaštite jest i upravljanje rizicima. Utvrdilo se da svaki deseti pacijent doživi medicinsku pogrešku. Iako su uzroci medicinskih pogrešaka vrlo raznoliki, vodeći je razlog medicinskih pogrešaka manjkava komunikacija među zdravstvenim osobljem ili između zdravstvenog osoblja i bolesnika/članova obitelji. Kako bi se izbjegle zamke manjkave komunikacije, a s ciljem unaprjeđenja kvalitete zdravstvene zaštite, razvijene su kontrolne liste – jedan od najpoznatijih alata kojima se poboljšava komunikacija te time i smanjuje učestalost propusta koji su mogli biti spriječeni.Quality healthcare is a basic right of every individual and as such is mentioned in numerous documents related to both patients’ rights and human rights. One of the components of health care quality is risk management. It was found that every tenth patient experiences a medical error. Although the causes of medical errors are very diverse, the leading cause of medical errors is poor communication among healthcare staff or between healthcare staff and patients/family members. In order to avoid the pitfalls of poor communication, and to improve the quality of health care, checklists were developed – one of the best-known tools for improving communication and thereby reducing the frequency of errors that could have been prevented

Patient identification and prevention of patient misidentification as a standard of patient safety in health care process

Sigurnost bolesnika je jedna od osnovnih smjernica za kvalitetno provođenje zdravstvene skrbi. Povećanje sigurnosti sustava zdravstvene zaštite rezultira nižom stopom neželjenih događaja, čime su bolesnici sigurniji od pogrešaka koje im se mogu dogoditi u zdravstvenom sustavu. Jedan od mogućih neželjenih događaja u sustavu zdravstvene zaštite jest zamjena identiteta bolesnika. Iako se često problemom zamjene identiteta bolesnika bavimo tek nakon što se takav neželjeni događaj već zbio, ključno je te događaje spriječiti. Postoje brojni načini koji se mogu primijeniti kako bi se smanjio rizik od zamjene identiteta bolesnika. Izbor odgovarajućeg načina sprječavanja zamjene identiteta bolesnika i mogućnost implementacije u svakodnevnu praksu te upotreba elektroničkih sustava ovise o specifičnosti samog sustava u kojem se određeni način za sprječavanje zamjene identiteta bolesnika planira primijeniti. Također, razvijanje i njegovanje kulture sigurnosti jedan je od ključnih čimbenika za sprječavanje zamjene identiteta bolesnika. Svijest i bolesnika i osoblja o važnosti provjere identiteta najvažniji su čimbenik u sprječavanju zamjene identiteta bolesnika. Prijavljivanje problema povezanih s točnom identifikacijom bolesnika, prijavljivanje zamjene identiteta bolesnika koja se dogodila ili se skoro dogodila (engl. near miss events) te njihova analiza ključni su za sprječavanje tih događaja u budućnosti.Patient safety is one of the basic guidelines for high-quality implementation of healthcare. Increasing the safety of the health care system results in a lower rate of unwanted events, which makes patients safer from mistakes that can happen to them in the health care system. One of the possible unwanted events in the health care system is patient misidentification. Although we often deal with the problem of patient misidentification only after such unwanted event has already taken place, it is crucial to prevent it from happening. There are a number of ways to reduce the risk of patient misidentification. The choice of the most appropriate way for the prevention of patient misidentification, the possibility of implementation in everyday practice, as well as the use of electronic systems depend on the specificity of the system itself in which a certain method is planned to be applied. Also, the development and the nurturing of safety culture is one of the key factors for preventing patient misidentification. The awareness of both patients and staff about the importance of identity confirmation is the most important factor in the prevention of patient misidentification. The reporting of problems related to accurate patient identification, as well as the reporting of near miss events and their analysis are key to preventing these events in the future

Utjecaj traheotomije na klinički tijek ventilacijske pneumonije

Ventilator-associated pneumonia (VAP) is the most common infection among intensive care unit (ICU) patients. The aim of the present study was to evaluate the impact of tracheotomy on VAP clinical course. The study was conducted in a 15-bed Surgical and Neurosurgical ICU, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center in Zagreb, Croatia. All patients developing VAP during ICU stay were eligible for the study. In VAP patients not tracheotomized during ICU stay, the mortality rate was approximately two times higher as compared with patients tracheotomized either before or after VAP onset (crude risk ratio 1.83, 95% confidence interval (95% CI) 1.15-2.91, p=0.01; crude odds ratio 3.47, 95% CI 1.52-7.94; p=0.003). In the surviving VAP patients, the duration of mechanical ventilation before VAP onset was higher in the “T before VAP” group as compared with the “no T before VAP” group (8, 6-10 vs. 3, 2-5; p<0.001), but the number of post-VAP days on mechanical ventilation was shorter in “T before VAP” patients than in “no T before VAP” patients (0, 0-1 vs. 4, 3-9; p<0.001). The duration of mechanical ventilation after VAP onset in the “T after VAP” group was longer as compared with the “T before VAP” group (4, 3-12 vs. 0, 0-1; p<0.001). The present study indicated tracheotomy to be associated with a reduced duration of mechanical ventilation after VAP onset, but only if patients were tracheotomized at the moment of VAP onset.Ventilacijska pneumonija (ventilator-associated pneumonia, VAP) je jedna od najčešćih infekcija među bolesnicima u jedinicama intenzivnog liječenja (JIL). Cilj ovoga istraživanja je bio utvrditi utjecaj traheotomije na klinički tijek VAP-a. Istraživanje je provedeno u 15-krevetnoj Jedinici intenzivnog liječenja Odjela za anesteziologiju, reanimatologiju i intenzivno liječenje u Kliničkom bolničkom centru “Sestre milosrdnice”, Zagreb, Hrvatska. Svi bolesnici u kojih se razvila VAP tijekom navedenog razdoblja bili su uključeni u istraživanje. U bolesnika s VAP koji nisu traheotomirani (T) tijekom njihovog boravka u JIL-u smrtnost je bila otprilike dva puta veća u usporedbi s bolesnicima koji su traheotomirani prije ili nakon razvoja VAP (crude risk ratio 1,83, 95% confidence interval (CI) 1,15-2,91, p=0,01; crude odds ratio 3,47, 95% CI 1,52-7,94; p=0,003). Među preživjelim bolesnicima trajanje mehaničke ventilacije prije razvoja VAP je bilo duže u skupini “T prije VAP” u usporedbi sa skupinom “bez T prije VAP” (8, 6-10 prema 3, 2-5; p<0,001), ali je broj dana mehaničke ventilacije nakon razvoja VAP bio kraći u bolesnika skupine “T prije VAP” u usporedbi s onima skupine “bez T prije VAP” (0, 0-1 prema 4, 3-9; p<0,001). Trajanje mehaničke ventilacije nakon razvoja VAP u skupini “T nakon VAP” je bilo duže u usporedbi sa skupinom “T prije VAP” (4, 3-12 prema 0, 0-1; p<0,001). Ovo istraživanje je ukazalo na to da je traheotomija povezana s kraćim trajanjem mehaničke ventilacije nakon pojave VAP, ali samo ako su bolesnici u trenutku pojave VAP traheotomirani

Analysis of out-of-hospital cardiac arrest in Croatia – survival, bystander cardiopulmonary resuscitation, and impact of physician’s experience on cardiac arrest management: a single center observational study

Aim To analyze the initial rhythm, bystander cardiopulmonary resuscitation (CPR) rate, and survival after out-of-hospital cardiac arrests (OHCA) in Varaždin County (Croatia), and to investigate whether physician’s inexperience in emergency medical services (EMS) has an impact on resuscitation management. Methods We reviewed clinical records and Revised Utstein cardiac arrest forms of all out-of-hospital resuscitations performed by EMS Varaždin (EMSVz), Croatia, from 2007-2013. To analyze the impact of physician’s inexperience in EMS (<1 year in EMS) on resuscitation management, we assessed physician’s turnover in EMSVz, as well as OHCA survival, airway management, and adherence to resuscitation guidelines in regard to physician’s EMS experience. Results Of 276 patients (median age 68 years, interquartile range [IQR] 16; 198 male; 37% ventricular fibrillation/ventricular tachycardia, bystander CPR rate 25%), 80 were transferred to hospital and 39 were discharged (median survival after discharge 23 months, IQR 46 months). During the 7-year study period, 29 newly graduated physicians inexperienced in EMS started to work in EMSVz (performing 77 resuscitations), while 48% of them stayed for less than one year. Airway management depended on physician’s EMS experience (P = 0.018): inexperienced physicians performed bag-valve-mask ventilation (BMV) more than the experienced, with no impact on survival rate. Physician’s EMS experience did not influence adherence to resuscitation guidelines (P = 0.668), survival to hospital discharge (P = 0.791), or survival time (P = 0.405). Conclusion OHCA survival rate of EMSVz resuscitations was higher than in Europe, but bystander CPR needs to be improved. Compared to experienced physicians, inexperienced physicians preferred BMV over intubation, but with similar adherence to resuscitation guidelines and survival after OHCA

ORAL CAVITY COLONIZATION WITH MULTIDRUG-RESISTANT GRAM-NEGATIVE BACTERIA AFTER PREOPERATIVE PROPHYLACTIC USE OF ANTIBIOTICS AS A RISK FACTOR FOR VENTILATOR-ASSOCIATED PNEUMONIA

Background: Although it was previously shown that prolonged prophylactic antibiotic exposure and multiple inadequate antibiotic therapies are independent risk factors for multidrug-resistant ventilator associated pneumonia there were no studies investigating whether pre-operative prophylactic dose of antibiotics changes oral microbiome and increases the risk of ventilator associated pneumonia. The aim of the study was to determine if pre-operative prophylactic dose of antibiotics affects the oral microbiome, increases the colonization with Gram-negative bacteria and subsequent risk of ventilator associated pneumonia. Subjects and methods: Mechanically ventilated adult patients receiving surgical antibiotic prophylaxis were included in the study. The presence of Gram negative microorganisms in the pre-prophylactic and post-prophylactic oral swabs and tracheal aspirates, as well as the occurrence of ventilator associated pneumonia, were analyzed. Results: Number of patients colonized with Gram negative bacteria in post- prophylactic oral swab was significantly higher compared to oral swab taken before prophylactic antibiotic. On the other hand, the number of patients with Gram- negative bacteria in tracheal aspirates remained similar as in post- prophylactic oral swabs. Moreover, we found that presence of Gram- negative bacteria in both pre- and post- prophylactic oral swabs was in the positive correlation with the presence of Gram- negative bacteria in tracheal aspirates. Conclusions: This study showed increased colonization of oral cavity with Gram- negative bacteria after preoperative prophylactic antibiotics. Furthermore, receiving two prophylactic antibiotics from WHO Watch list increased the incidence of Gramnegative bacteria in oral swabs and tracheal aspirates, and the risk of ventilator associated pneumonia development

ORAL CAVITY COLONIZATION WITH MULTIDRUG-RESISTANT GRAM-NEGATIVE BACTERIA AFTER PREOPERATIVE PROPHYLACTIC USE OF ANTIBIOTICS AS A RISK FACTOR FOR VENTILATOR-ASSOCIATED PNEUMONIA

Background: Although it was previously shown that prolonged prophylactic antibiotic exposure and multiple inadequate antibiotic therapies are independent risk factors for multidrug-resistant ventilator associated pneumonia there were no studies investigating whether pre-operative prophylactic dose of antibiotics changes oral microbiome and increases the risk of ventilator associated pneumonia. The aim of the study was to determine if pre-operative prophylactic dose of antibiotics affects the oral microbiome, increases the colonization with Gram-negative bacteria and subsequent risk of ventilator associated pneumonia. Subjects and methods: Mechanically ventilated adult patients receiving surgical antibiotic prophylaxis were included in the study. The presence of Gram negative microorganisms in the pre-prophylactic and post-prophylactic oral swabs and tracheal aspirates, as well as the occurrence of ventilator associated pneumonia, were analyzed. Results: Number of patients colonized with Gram negative bacteria in post- prophylactic oral swab was significantly higher compared to oral swab taken before prophylactic antibiotic. On the other hand, the number of patients with Gram- negative bacteria in tracheal aspirates remained similar as in post- prophylactic oral swabs. Moreover, we found that presence of Gram- negative bacteria in both pre- and post- prophylactic oral swabs was in the positive correlation with the presence of Gram- negative bacteria in tracheal aspirates. Conclusions: This study showed increased colonization of oral cavity with Gram- negative bacteria after preoperative prophylactic antibiotics. Furthermore, receiving two prophylactic antibiotics from WHO Watch list increased the incidence of Gramnegative bacteria in oral swabs and tracheal aspirates, and the risk of ventilator associated pneumonia development

Childhood-onset systemic lupus erythematosus in Croatia: demographic, clinical and laboratory features, and factors influencing time to diagnosis

OBJECTIVES Childhood-onset systemic lupus erythematosus (cSLE) presents with diverse clinical features and often with non-classical symptoms that may delay diagnosis and increase risk of morbidity and mortality. This paper aims to analyse incidence, and clinical and laboratory features of cSLE in Croatia between 1991 and 2010, and to identify factors influencing time to diagnosis. ----- RESULTS Medical records at three university-based tertiary care centres were analysed retrospectively for 81 children with cSLE (68 girls). Mean age at onset was 13.4±2.8 yr (interquartile range 3), and annual incidence varied from 1-15 per million at risk. The most frequent clinical and laboratory features were musculoskeletal symptoms (80%) and increased erythrocyte sedimentation rate (96%). The most frequent immunological laboratory findings were the presence of antibodies against histones (86%), double-stranded DNA (73%), and Sm protein (64%), as well as low levels of C3 complement (69%). Haematuria was present in 58% of children, proteinuria in 56%, and biopsy-confirmed lupus nephritis in 43%. Median time from symptom onset to diagnosis was 2 months (range 0-96). Time to diagnosis was inversely associated with ECLAM score (p<0.001), but it showed no association with age, gender, clinical features or distance from the nearest paediatric centre. ----- CONCLUSIONS This is the first large-scale, in-depth study of clinical and laboratory features of cSLE in Croatia. Among all demographic, laboratory and clinical features examined, ECLAM score alone was inversely associated with time to diagnosis. This highlights the need to improve detection of children with fewer symptoms early in the course of the disease, therefore serious consequences for prognosis could be avoided