Postoperacijsko liječenje bolesnika s mehaničkom potporom srca u jedinici intenzivnog liječenja.

After the implantation of the left ventricular assisted device (LVAD), patients are admitted in intensive care unit (ICU). During the period of first several days, the goal of the postoperative care is to stabilize the patients’ hemodynamics. Monitoring the continuous cardiac output, filling volumes and outflow resistance is necessary for the proper functioning of the pump. The use of pulmonary artery catheter and the transesophageal echocardiography are primary procedures. During the operation of the left ventricular support, the measuring of proper ventricular function and the early recognition of its dysfunction is important for a positive outcome. Further potential complications in connection with these patients are an increased risk of hemorrhage and thromboembolism. The infection of drivelines and devices in the early postoperative period occurs in up to 40 % of these patients. In case of a cardiac arrest, a special procedure has to be performed in patients in whom LVAD was implanted. Finally, we have shown the anesthesiologic management in cases when patients with LVAD have to undergo noncardiac surgery.Nakon ugradnje lijevostrane srčane potpore (LSP), bolesnici se zaprimaju u jedinicu intenzivne medicine. Tijekom ovog razdoblja od nekoliko dana, osnovni cilj poslijeoperacijskog liječenja je stabilizacija bolesnikove hemodinamike. Praćenje kontinuiranog minutnog volumena, tlakova punjenja i sustavne rezistencije je neophodno za ispravno funkcioniranje LSP-a. Uporaba plućnog arterijskog katetera s kontinuiranim mjerenjem minutnog volumena te transezofagijska ehokardiografija su primarni postupci. Za vrijeme rada LSP, praćenje funkcije desne klijetke te rano uočavanje njene disfunkcije od krucijalnog su značaja za dobar ishod bolesnika. Daljnje moguće komplikacije u ovih bolesnika su povećani rizik od krvarenja, kao i od nastanka tromboembolija. Incidencija infekcija u ovih bolesnika je visoka, i kreće se do 40%, osobito infekcije kanila. U slučaju zastoja rada srca, primjenjuju se posebni postupci oživljavanja, koji se razlikuju od uobičajenih algoritama. Na kraju, prikazane su i specifičnosti anesteziološkog postupka u ovih bolesnika ukoliko postoji potreba za nekardijalnom operacijom

Neuroethics

Neuroetika se definira kao primijenjena bioetika u svim područjima neurologije, uključujući neuroznanost, neurotehnologiju, neurofarmakologiju i neuroradiologiju. Neologizam neuroetika prvi put se spominje 1993. u raspravi o moralnom razvoju. Najčešća definicija neuroetike odnosi se na etičke, pravne i socijalne utjecaje na razvoj i primjenu neuroznanosti.Neuroethics is the term referring to bioethics in the field on neuroscience, neurotechnology, neuropharmacology and neuroradiology. According to Web of Science, this neologism was probably first used in 1993 by A.A. Pontius in a discussion on the development, published in Psychological Reports. The most frequent definition of neuroethics includes ethical, legal amd social infuences on the development and application of neuroscience

Private equity and business budgeting

This study investigates the connection between private equity funds and business budgeting. The study is based on the data from SEAF South Balkan Fund B.V., a private equity fund, which, during the 2006 to 2010 period, analyzed 483 companies in Serbia. To that end, the first part of the study presents the conceptual framework, as well as different private equity funds, such as venture capital funds, leveraged buyout funds, mezzanine funds, etc. The second part of the study shows different types of budgets, their features and characteristics, as well as different budgeting processes, methods and strategic approaches. In the third part, the connection between private equity investing and business budgeting is established. Lastly, the conclusion is drawn that the business budgeting is an important factor in creating successful companies, but that many business owners, in Serbia, do not realize its importance, or perform it

Early Cardioprotective Effect of Sevoflurane on Left Ventricular Performance during Coronary Artery Bypass Grafting on a Beating Heart: Randomized Controlled Study

Cilj Procijeniti kardioprotektivni učinak sevoflurana na rad lijeve srčane klijetke za vrijeme presađivanja prjemosnice koronarne arterije na kucajućemu srcu s normalnom prijeoperacijskom funkcijom lijeve klijetke. Postupci Randomizirana kontrolirana studija uključila je 32 bolesnika kojima je anestezija inducirana sevofluranom a potom su randomizirani za primanje 1 minimalne alveolarne koncentracije (MAC) sevoflurana pri završetku udisaja (n=16) ili 2 do 3 mg kg-1 h-1 propofola (n=16). Mjereni su ubrzanje tijeka krvi u aorti, srčani indeks i frekvencija, srednji arterijski i središnji venski tlak, i to 5 minuta nakon indukcije anestezije, na početku i nakon 15 minuta trajanja ishemije, te 15 minuta nakon zatvaranja prsne kosti. Rezultati Srčana frekvencija, srednji arterijski i središnji venski tlak nisu se razlikovali ni unutar ni između dvaju skupina bolesnika. U skupini koja je primila sevofluran povećalo se ubrzanje 15 minuta nakon ishemije (10,3±3,5 m/s2; P=0,004) i 15 minuta nakon zatvaranja prsne kosti (10,7±3,9m/s2; P<0,001). U skupini koja je primila propofol group ubrzanje se smanjilo nakon početka ishemije (P<0,001) i ostalo je smanjeno 15 minuta nakon zatvaranja prsne kosti (P=0,001 odnosno P=0,024). Na početku ishemije i 15 minuta nakon zatvaranja prsne kosti ubrzanje je bilo veće u skupini koja je primila sevofluran (P=0,017 odnosno P=0,046). U skupini koja je primila sevofluran nisu se pojavile razlike u srčanom indeksu, a u skupini koja je primila propofol srčani se indeks značajno smanjio na početku ishemije (P<0,001). Na početku ishemije i 15 minuta nakon toga srčani se indeks značajno razlikovao između dvije skupine (P=0,002 odnosno P=0,011). Zaključak Srčana funkcija bila je bolje očuvana u bolesnika anesteziranih sevofluranom nego u onih anesteziranih propofolom.Aim To evaluate the cardioprotective effect of sevoflurane on a beating heart in patients undergoing coronary artery bypass grafting with normal preoperative left ventricular function. Methods The randomized controlled study included 32 patients induced with sevoflurane and then randomized to receive either 1 minimal alveolar concentration (MAC) end-tidal concentration of sevoflurane (n = 16) or propofol (n = 16) 2 to 3 mg kg–1 hour–1. The acceleration of the aortic blood flow, cardiac index, heart rate, mean arterial pressure, and central venous pressure were measured 5 minutes after anesthesia induction, at the beginning of ischemia, 15 minutes after ischemia, and 15 minutes after sternum closure. Results There were no differences in heart rate, mean arterial pressure, and central venous pressure within each group and between groups during surgery. Acceleration increased in the sevoflurane group 15 minutes after ischemia (10.3 ± 3.5 m/s2; P = 0.004) and 15 minutes after sternum closure (10.7 ± 3.9 m/s2; P<0.001). Acceleration in the propofol group decreased from the beginning of ischemia (P<0.001) and remained lower 15 minutes after sternum closure (P = 0.001 and P = 0.024, respectively). Acceleration was higher in the sevoflurane group at the beginning of ischemia and 15 minutes after sternum closure (P = 0.017 and P = 0.046, respectively). There were no significant differences in cardiac index values within the sevoflurane group. In the propofol group, significant decreases in cardiac index were seen at the beginning of ischemia (P<0.001). There were between-group differences in cardiac index values at the beginning of ischemia and 15 minutes after ischemia (P = 0.002, and P = 0.011, respectively). Conclusion Cardiac function was better preserved in the patients anesthetized with sevoflurane than in patients anesthetized with propofol

Hemodynamic Differences in Sevoflurane Versus Propofol Anesthesia

The aim of the study was to compare the effect of sevoflurane and propofol anesthesia on myocardial contractility during laparotomic cholecystectomy using transesophageal echo-Doppler. In the study, 40 patients were randomized into two groups, depending on whether they received sevoflurane or propofol anesthesia. Heart rate, cardiac index, stroke volume, left ventricular ejection time and acceleration were measured 10 minutes after induction of anesthesia, 1 minute and 25 minutes after incision. The results were analyzed using paired t-test and ANOVA. Significantly lower values were found for all parameters after the initial measurement (p<0.05). In the sevoflurane group, stroke volume decreased from 666.2 ml/beat to 656.4 ml/beat and to 635.6 ml/beat 1 minute and 25 minutes after incision respectively. In the propofol group changes were from 64 ml/beat to 5810.5 ml/beat to 588.6 ml/beat. Stroke volume was significantly higher in the sevoflurane than in the propofol group (p<0.05). Sevoflurane anesthesia allows a better hemodynamic stability during laparotomic cholecystectomy

ELECTRICAL IMPEDANCE TOMOGRAPHY – CASE REPORT WITH SHORT REVIEW OF TECHNOLOGY AND CLINICAL APPLICATION SCENARIOS

Električna impedancijska tomografi ja (EIT) je neinvazivna metoda praćenja koja se u prvom redu koristi za procjenu regionalne distribucije ventilacije u plućima, ali je dokumentirana i druga uporaba (kao što je procjena distribucije perfuzije). Temelji se na fi zikalnom principu razlike u impedancijama različitih tkiva ili razlika u prozračenosti plućnog tkiva. Tomogram se zatim dinamički generira pomoću računalnog softvera i slikovno prikazuje. Klinički je prihvatljiva korelacija između EIT i kompjuterizirane tomografi je (engl. computed tomography - CT) za procjenu reverzibilnog alveolarnog kolapsa, što čini EIT vrijednim dijagnostičkim sredstvom za prilagođivanje postavki mehaničke ventilacije i regrutiranje alveola kod bolesnika s akutnim respiratornim distres sindromom (engl. acute respiratory distress syndrome – ARDS). Prikazujemo bolesnika primljenog u jedinicu intenzivne medicine (JIM) zbog ARDS-a koji je izazvan intraoperacijskom aspiracijom želučanog sadržaja. Nakon započinjanja mehaničke ventilacije i bronhoskopske lavaže, uz pomoć EIT provedeno je određivanje razine pozitivnog tlaka na kraju ekspirija (engl. positive end expiratory pressure – PEEP) potrebne da se izbjegne alveolarna predistendiranost ili kolaps. PEEP vrijednost od 14 mbara utvrđena je kao najniža razina PEEP iznad alveolarnog kolapsa. Plinske analize arterijske krvi nakon određivanja navedene razine PEEP pokazale su značajno poboljšanje u odnosu na početne vrijednosti, pa je pacijent sljedeći dan ekstubiran, otpušten iz JIM-a nakon dva dana i iz bolnice 4 dana kasnije bez ikakvih respiratornih komplikacija.Electrical impedance tomography (EIT) is a noninvasive monitoring method which is primarily used to assess regional distribution of ventilation in the lungs, but other uses (such as perfusion mapping) have been documented as well. It works on the physical principle of varying impedance of various tissues or differences in aeration of lung tissue. A tomogram is then dynamically generated by computer software to show regional distribution of ventilation. Clinically agreeable correlation was found between EIT and computed tomography (CT) assessment of recruitable alveolar collapse, which makes EIT a valuable bedside diagnostic tool to aid recruitment maneuvers in patients with acute respiratory distress syndrome (ARDS). We present a patient with ARDS induced by intraoperative aspiration of gastric contents, who was admitted to the intensive care unit (ICU). After initiation of mechanical ventilation and bronchoscopy guided alveolar lavage, stepwise positive end expiratory pressure (PEEP) trial was performed using EIT to detect alveolar overdistension or collapse. PEEP value of 14 mbar was established as the lowest level of PEEP above alveolar collapse. Arterial blood gas tests after the trial showed marked improvement over baseline values, the patient was extubated on the next day, discharged from the ICU two days later, and discharged from the hospital 4 days later without any respiratory complications

ELECTRICAL IMPEDANCE TOMOGRAPHY – CASE REPORT WITH SHORT REVIEW OF TECHNOLOGY AND CLINICAL APPLICATION SCENARIOS

Električna impedancijska tomografi ja (EIT) je neinvazivna metoda praćenja koja se u prvom redu koristi za procjenu regionalne distribucije ventilacije u plućima, ali je dokumentirana i druga uporaba (kao što je procjena distribucije perfuzije). Temelji se na fi zikalnom principu razlike u impedancijama različitih tkiva ili razlika u prozračenosti plućnog tkiva. Tomogram se zatim dinamički generira pomoću računalnog softvera i slikovno prikazuje. Klinički je prihvatljiva korelacija između EIT i kompjuterizirane tomografi je (engl. computed tomography - CT) za procjenu reverzibilnog alveolarnog kolapsa, što čini EIT vrijednim dijagnostičkim sredstvom za prilagođivanje postavki mehaničke ventilacije i regrutiranje alveola kod bolesnika s akutnim respiratornim distres sindromom (engl. acute respiratory distress syndrome – ARDS). Prikazujemo bolesnika primljenog u jedinicu intenzivne medicine (JIM) zbog ARDS-a koji je izazvan intraoperacijskom aspiracijom želučanog sadržaja. Nakon započinjanja mehaničke ventilacije i bronhoskopske lavaže, uz pomoć EIT provedeno je određivanje razine pozitivnog tlaka na kraju ekspirija (engl. positive end expiratory pressure – PEEP) potrebne da se izbjegne alveolarna predistendiranost ili kolaps. PEEP vrijednost od 14 mbara utvrđena je kao najniža razina PEEP iznad alveolarnog kolapsa. Plinske analize arterijske krvi nakon određivanja navedene razine PEEP pokazale su značajno poboljšanje u odnosu na početne vrijednosti, pa je pacijent sljedeći dan ekstubiran, otpušten iz JIM-a nakon dva dana i iz bolnice 4 dana kasnije bez ikakvih respiratornih komplikacija.Electrical impedance tomography (EIT) is a noninvasive monitoring method which is primarily used to assess regional distribution of ventilation in the lungs, but other uses (such as perfusion mapping) have been documented as well. It works on the physical principle of varying impedance of various tissues or differences in aeration of lung tissue. A tomogram is then dynamically generated by computer software to show regional distribution of ventilation. Clinically agreeable correlation was found between EIT and computed tomography (CT) assessment of recruitable alveolar collapse, which makes EIT a valuable bedside diagnostic tool to aid recruitment maneuvers in patients with acute respiratory distress syndrome (ARDS). We present a patient with ARDS induced by intraoperative aspiration of gastric contents, who was admitted to the intensive care unit (ICU). After initiation of mechanical ventilation and bronchoscopy guided alveolar lavage, stepwise positive end expiratory pressure (PEEP) trial was performed using EIT to detect alveolar overdistension or collapse. PEEP value of 14 mbar was established as the lowest level of PEEP above alveolar collapse. Arterial blood gas tests after the trial showed marked improvement over baseline values, the patient was extubated on the next day, discharged from the ICU two days later, and discharged from the hospital 4 days later without any respiratory complications

Rana klinička iskustva sa dugoročnom potporom (Heart Mate II)

Left ventricular assist systems (LVAS) are widely accepted nowadays as a successful tool for bridging the patients with end-stage heart failure to heart transplantation (BTT). The second generations of axial-flow devices, such as the HeartMate II, provide a safe and reliable, as well as an effective hemodynamic support in such patients, offering them an improved quality of life; they are furthermore associated with a very low rate of device malfunction or infection requiring device change. We report here of our first three patients with the implanted HM II LVAS as a BTT .Uređaji za potporu lijevom srcu (LVAS – left ventricular assist system) su danas prihvaćeni kao uspiješno sredstvo za premoštenje bolesnika u završnom stadiju zatajivanja srca do transplantacije. Druga generacija aksijalnih pumpi, kao što je HeartMate II , pruža sigurnu i učinkovitu hemodinamsku potporu takvim bolesnicima, poboljšavajući kvalitetu života. Danas su ti uređaji povezani sa niskom inicidencijom malfunkcije ili infekcije koje bi zahtijevale zamjenu. Prikazujemo naša tri bolesnika kojima je ugrađen HeartMate II LVAS kao premoštenje do transplantacije

Ventricular Assist Device Support in Advanced Heart Failure Patient with Congenitally Corrected Transposition of the Great Arteries and Dextrocardia- Case Report and Review

Kongenitalno korigirana transpozicija velikih arterija (ccTGA) kongenitalna je srčana malformacija s incidencijom od 0,5% svih bolesnika s urođenim srčanim manama. Dekstrokardija je zabilježena među tim bolesnicima i do 20%. U ovom radu prikazujemo 52-godišnju pacijenticu s ccTGA i dekstrokardijom sa situs solitusom. Zbog kongestivnog zatajenja srca otpornog na lijekove i visokog plućnog vaskularnog otpora multidisciplinarni tim odlučio se za dugoročno rasterećenje s ventrikularnim pomoćnim uređajem kao prijelaznim rješenjem do indikacije za transplantaciju srca. U rujnu 2017. ugrađen je intraperikardijalni ven- trikularni pomoćni uređaj. Precizno slikanje (transtorakalna ehokardiografija s kontrastom, transoezofagična ehokardiografija, MSCT srca) u multidisciplinarnom srčanom timu ključni su za uspješnu implantaciju intraperikardijalnog VAD-a malih dimenzija kod pacijenta sa složenom anatomijom poput one u ccTGA i dekstrokardija. Budući da se postojeća literatura sastoji uglavnom od izvještaja o slučajevima, odluke u liječenju trebale bi uključivati postupno uvođenje modaliteta liječenja i pomno praćenje kliničkog odgovora, kao i multidisciplinarnog tima za rad srca.Congenitally corrected transposition of the great arteries (ccTGA) is congenital cardiac malformation with an incidence of 0.5% of all patients with congenital heart defects. Dextrocardia is reported among these patients up to 20%. We report a 52-year old female patient with ccTGA and dextrocardia with situs solitus. Due to congestive heart failure refractory to medications and high pulmonary vascular resistance multidis- ciplinary team decided for long term unloading with ventricular assist device as a bridge to heart transplant candidacy. In September 2017 intrapericardial ventricular assist device (centrifugal continuous flow, fully magnetically-levitated technology) was implanted in failing systemic ventricle. Accurate imaging (trans- thoracic echocardiography with contrast, transoesophagic echocardiography, cardiac MSCT) in multidis- ciplinary heart team is pivotal in successful implantation of small size intrapericardial VAD in patient with complex anatomy as ccTGA and dextrocardia. Because the existing literature consists mainly of case reports, management should include the stepwise introduction of the treatment modalities and close monitoring of the clinical response as well as heart multidisciplinary team