Diabetic ketoacidosis and electrolyte disorders in patient with short bowel syndrome following acute mesenteric ischemia

Acute mesenteric ischemia (AMI) is defined as a sudden occurrence of insufficient blood supply to the intestine that can lead to necrosis (gangrene) of the intestine wall or its ischemia alone. It is therefore a life-threatening condition that requires rapid diagnosis and proper treatment. In presence of irreversible ischemic lesions the only treatment option is surgery. Short bowel syndrome commonly develops as a result of such treatment and can be a precipitating factor for the emergence of acid-base and electrolyte disorders

Značenje agregacije trombocita u bolesnika s bubrežnim zatajenjem

The exact etiology of the conflicting hemostatic disorder in the advanced stage of chronic renal disease, i.e. prothrombotic versus bleeding tendency, is not completely understood. Abnormal platelet function in patients with renal failure is not caused by high concentrations of urea, although the presence of fibrinogen fragments may prevent binding of normal fibrinogen and formation of platelet aggregates. Hemostatic abnormalities in end-stage kidney disease may be affected, to some extent, by the choice of renal replacement therapy. Patients on hemodialysis have an increased risk of thrombotic events, primarily due to the release of thromboxane A2 and adenosine diphosphate into the circulation, as well as platelet degranulation. Some activation of platelets occurs due to the exposure of blood to the roller pump segment, but microbubbles may also play a role. Renal transplantation is the treatment of choice for patients with end-stage renal disease. Immunosuppressive therapy is associated with an increased risk of thromboembolic complications. Additional research is required to identify the potential benefits of different immunosuppressive therapies in relation to platelet aggregation, keeping in mind the long term need for immunosuppression in renal transplant patients.Točna etiologija proturječnih hemostatskih poremećaja u terminalnom stadiju bubrežne bolesti, tj. tromboze i sklonosti krvarenju, nije u potpunosti razjašnjena. Poremećena funkcija trombocita u bolesnika s bubrežnim zatajenjem nije uzrokovana povišenom koncentracijom ureje, premda prisutnost fragmenata fibrinogena može spriječiti vezivanje normalnog fibrinogena, odnosno stvaranje agregata tromobocita. Na poremećaj hemostaze kod bolesnika s bubrežnim zatajenjem može utjecati i izbor nadomjesnog bubrežnog liječenja. Bolesnici na hemodijalizi imaju povećani rizik tromboze prvenstveno zbog oslobađanja tromboksana A2 i ADP -a u cirkulaciju, kao i zbog degranulacije trombocita. U stanovitoj mjeri trombociti se aktiviraju i prolaskom krvi kroz sustav crpki, dok moguću ulogu imaju i mikromjehurići. Transplantacija bubrega je metoda izbora u liječenju bolesnika s bubrežnim zatajenjem. Imunosupresivna terapija je povezana s povećanim rizikom razvoja trombembolijskih komplikacija. Imajući u vidu dugotrajnu potrebu za imunosupresivnim liječenjem kod bolesnika s transplantiranim bubregom potrebna su daljnja istraživanja radi utvrđivanja mogućeg povoljnog učinka različitih imunosupresiva u odnosu na agregaciju trombocita

Značenje agregacije trombocita u bolesnika s bubrežnim zatajenjem

The exact etiology of the conflicting hemostatic disorder in the advanced stage of chronic renal disease, i.e. prothrombotic versus bleeding tendency, is not completely understood. Abnormal platelet function in patients with renal failure is not caused by high concentrations of urea, although the presence of fibrinogen fragments may prevent binding of normal fibrinogen and formation of platelet aggregates. Hemostatic abnormalities in end-stage kidney disease may be affected, to some extent, by the choice of renal replacement therapy. Patients on hemodialysis have an increased risk of thrombotic events, primarily due to the release of thromboxane A2 and adenosine diphosphate into the circulation, as well as platelet degranulation. Some activation of platelets occurs due to the exposure of blood to the roller pump segment, but microbubbles may also play a role. Renal transplantation is the treatment of choice for patients with end-stage renal disease. Immunosuppressive therapy is associated with an increased risk of thromboembolic complications. Additional research is required to identify the potential benefits of different immunosuppressive therapies in relation to platelet aggregation, keeping in mind the long term need for immunosuppression in renal transplant patients.Točna etiologija proturječnih hemostatskih poremećaja u terminalnom stadiju bubrežne bolesti, tj. tromboze i sklonosti krvarenju, nije u potpunosti razjašnjena. Poremećena funkcija trombocita u bolesnika s bubrežnim zatajenjem nije uzrokovana povišenom koncentracijom ureje, premda prisutnost fragmenata fibrinogena može spriječiti vezivanje normalnog fibrinogena, odnosno stvaranje agregata tromobocita. Na poremećaj hemostaze kod bolesnika s bubrežnim zatajenjem može utjecati i izbor nadomjesnog bubrežnog liječenja. Bolesnici na hemodijalizi imaju povećani rizik tromboze prvenstveno zbog oslobađanja tromboksana A2 i ADP -a u cirkulaciju, kao i zbog degranulacije trombocita. U stanovitoj mjeri trombociti se aktiviraju i prolaskom krvi kroz sustav crpki, dok moguću ulogu imaju i mikromjehurići. Transplantacija bubrega je metoda izbora u liječenju bolesnika s bubrežnim zatajenjem. Imunosupresivna terapija je povezana s povećanim rizikom razvoja trombembolijskih komplikacija. Imajući u vidu dugotrajnu potrebu za imunosupresivnim liječenjem kod bolesnika s transplantiranim bubregom potrebna su daljnja istraživanja radi utvrđivanja mogućeg povoljnog učinka različitih imunosupresiva u odnosu na agregaciju trombocita

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

The hemodynamic effect of intermediate cervical plexus block compared to general anesthesia in high risk patients with carotid endarterectomy

Background and purpose: Preventive open carotid surgery is amainstay treatment for stenosis of internal carotid artery. Anesthesia management is crucial in these patients with many comorbidities. Both, general or regional anesthesia are the correct choice. The purpose of our trialwas to compare the hemodynamic stability of intermediate cervical plexus block relative to general anesthesia in ASA III and ASA IV patients. Materials and methods: Prospective study, approved by ethics committee, was conducted in the University hospital Zagreb from 2006 till 2010. Eighty nine high risk patients with carotid endarterectomy were enrolled. Thirty five patients were performed in the intermediate cervical block and fifty four in general anesthesia. From medical records, following data were collected – age, sex, ASA status. Mean arterial pressure was calculated. The change of mean arterial pressure during the operation for more than 20% was considered as hemodynamic instability. Postoperative hospital stay was recorded. Results: Significantly higher hemodynamic stability is found in the group of patientswith intermediate cervical block (chi-square test=27,763, p<0,01). The median intensive care unit stay was 2,47 days for general anesthesia group, compared to one day for intermediate cervical group. Conclusion: General anesthesia and intermediate cervical block provide effective anesthesia condition for carotid endarterectomy. According to the results of our trial, intermediate cervical block compared to general anesthesia is more hemodynamic stable, associated with shorter hospital stay

AGREGACIJA TROMBOCITA U ZAVRŠNOM STADIJU ZATAJIVANJA BUBREGA – RAZLIKE IZMEĐU BOLESNIKA KOJI SU LIJEČENI HEMODIJALIZOM I PERITONEJSKOM DIJALIZOM

End-stage renal disease patients (ESRD) suffer from procoagulant abnormalities that lead to excessive cardiovascular events, as well as from platelet dysfunction manifesting as an increased risk of bleeding. The exact pathogenesis of complex hemostatic disorders in ESRD patients is not completely understood. The aim of our study was to investigate the possible different effects of hemodialysis (HD) and peritoneal dialysis (PD) on platelet function in patients with ESRD by using the platelet function analyzer (PFA-100) which in vitro simulates the process of aggregation and platelet activation. Tests were performed with collagen/epinephrine (COL/EPI) and collagen/adenosine-5-diphosphate (COL/ADP) cartridges. The study included 44 patients with ESRD undergoing regular HD (n=32) or PD (n=12). Although there were no significant differences in COL/EPI and COL/ADP tests, it is indicative that more than 50% of HD patients had COL/EPI test values above the upper limit. These findings correlated with a higher chance for bleeding in HD group.Additionally, patients in HD group were significantly older and had significantly lower platelet count compared to PD patients.Završni stadij kronične bubrežne bolesti obilježen je različitim prokoagulantnim odstupanjima koja dovode do razvoja tromboembolijskih komplikacija uz istodobno poremećenu funkciju trombocita s posljedičnim porastom rizika za nastanak krvarenja. Točna etiologija složenih hemostatskih poremećaja u završnom stadiju kronične bubrežne bolesti nije u potpunosti razjašnjena. Cilj ovoga istraživanja bio je usporediti učinak hemodijalize i peritonejske dijalize na funkciju tromobocita kod bolesnika u završnom stadiju kronične bubrežne bolesti primjenom analizatora funkcije trombocita (PFA-100) koji in vitro stimulira proces aktivacije i agregacije trombocita. Ispitivanje je provedeno na 2 testa (COL/EPI i COL/ADP) koji mjere vrijeme potrebno cirkulirajućoj krvi da okludira membranu obloženu kolagenom i adrenalinom (COL/EPI) odnosno kolagenom i ADP-om (COL/ADP). U istraživanje su bili uključeni bolesnici na hemodijalizi (n=32) odnosno peritonejskoj dijalizi (n=12). Premda nije zabilježena statistički značajna razlika između testova COL/EPI i COL/ADP, indikativno je da su u više od 50% ispitanika na hemodijalizi vrijednosti testa COL/EPI bile iznad gornje granice referentnog intervala. Ovi rezultati mogu se povezati s većom mogućnosti krvarenja u bolesnika na hemodijalizi. Uz to, bolesnici na hemodijalizi bili su značajno stariji te su imali statistički značajno niži broj trombocita u odnosu na ispitanike na peritonejskoj dijalizi

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)

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

Učinak inhalacijskih anestetika na akutno oštećenje bubrega

Acute kidney injury (AKI) is a serious complication associated with increased morbidity and mortality. Total incidence of AKI in hospitalized patients is 1%-5%. As many as 30% of these patients develop AKI in the perioperative period, which is associated with anesthesia and surgery. Despite scientific advances and improved surgery techniques, as well as treatment in intensive care units, no significant decrease in AKI incidence has been achieved. To change this outcome, it is important to identify patients at risk of AKI and prevent its occurrence. Correct selection of anesthetic drugs during general anesthesia, adjusted to the individual needs of patients, also influences the overall outcome of treatment. Nowadays, inhalational anesthetics are not considered nephrotoxic. The more so, inhalational anesthetics have a strong and direct protective effect on many organs through preconditioning and postconditioning. New studies have shown that sevoflurane diminishes ischemia/reperfusion kidney injury and has an anti-inflammatory effect, thus having the potential to reduce the occurrence of AKI. Given the incidence of AKI in the perioperative period, as well as new findings about anesthetics, the issue of anesthetic selection during general anesthesia might be of crucial importance for the final outcome of treatment.Akutno oštećenje bubrega (AOB) je ozbiljna komplikacija povezana s povišenim pobolom i smrtnošću. Ukupna incidencija AOB u bolničkih bolesnika iznosi 1%-5%. Čak 30% tih bolesnika su razvili AOB u perioperacijskom razdoblju kao posljedicu anestezije i operacije. Unatoč novim znanstvenim spoznajama i unaprjeđenju kirurških tehnika te liječenja u jedinicama intenzivne njege, nije postignut značajniji pomak u smanjenju incidencije AOB. Za promjenu tog ishoda važno je prepoznavanje rizične skupine bolesnika te prevencija. Na ukupni ishod liječenja utječe i pravilan odabir anestetičkih sredstava tijekom opće anestezije, koji je najbolje prilagođen individualnim potrebama bolesnika. Danas se smatra da inhalacijski anestetici nisu nefrotoksični. Dapače, inhalacijski anestetici imaju snažan izravan zaštitni učinak na mnoge organe kroz predkondicioniranje i postkondicioniranje. Nova istraživanja pokazuju da sevofluran smanjuje ishemijsko-reperfuzijsku ozljedu bubrega i djeluje protuupalno, zbog čega ima potencijal smanjiti pojavu AOB. S obzirom na incidenciju AOB u perioperacijskom razdoblju i nove spoznaje o anesteticima, pitanje odabira anestetika tijekom opće anestezije moglo bi biti od ključnog značenja za sveukupni ishod liječenja