CLINICAL COMPARISON OF INVOS OXYMETRY AND ARTERIAL LACTATE LEVELS AS A PREDICTOR OF PERIPHERAL PERFUSION AND REPERFUSION IN VASCULAR SURGERY PATIENTS

Cilj ovog probnog projekta je evaluacija primjene INVOS oksimetrije za optimalizaciju anesteziološkog postupka kod operacija reperfuzije donjih ekstremiteta u bolesnika s perifernom arterijskom bolešću (PAB). Ispitanici: U probnom projektu evaluirana su 4 bolesnika s kritičnom ishemijom donjih ekstremiteta. Uz elektrodu za indikaciju cerebralne perfuzije (crSO2), drugu INVOS elektrodu za indikaciju periferne perfuzije, postavili smo distalno od vaskularne kleme (prSO2). Dobivene podatke smo koristili kao prediktore periferne perfuzije i nužnosti intervencije, a podatke smo usporedili s koncentracijom laktata arterijske krvi. Rezultati: Početne prosječne crSO2 vrijednosti bile su 62,25 %, a prSO2 53,5 %. Prosječno trajanje arterijske okluzije bilo je 61 min. Pacijenti su primili u prosjeku 1275 mL kristaloida i 500 mL koloida. Najviše izmjerene vrijednosti laktata aterijske krvi bile su 0,7 mmol/L. Postoperacijski crSO2 iznosio je prosječno 73 %, a prSO2 69,75 %. Prosječna hospitalizacija trajala je 19,25 dana, s 30-dnevnim preživljavanjem od 100 %, bez potrebe reoperacije ili amputacije. Rasprava: Pretragom dostupne literature nismo pronašli sličnih kliničkih iskustava primjene optičke spektrometrije kao metode mjerenja intraoperacijske perfuzije ishemičnog ekstremiteta. Koristeći INVOS za poboljšanje perfuzije periferije koristili smo minimalnu vazoaktivnu potporu i restriktivnu bolusnu primjenu intravenskih tekućina uz zadovoljavajući klinički ishod.The aim of this pilot project was to evaluate the use of INVOS oxymetry to optimize anesthesia in lower extremities in patients with peripheral arterial disease (PAD). Four patients with critical ischemia of lower extremities were evaluated. With the electrode indicating cerebral perfusion (crSO2), another INVOS electrode was placed distally from the vascular clamp (prSO2). The data obtained were used as predictors of peripheral perfusion and necessity of intervention. We compared the aforementioned data with the arterial blood lactate levels. The initial mean crSO2 and prSO2 value was 62.25% and 53.5%, respectively. The mean duration of arterial occlusion was 61 minutes. The patients received a mean of 1275 mL crystalloids and 500 mL colloids. The highest measured lactate value was 0.7 mmol/L. Postoperative crSO2 averaged 73% and prSO2 69.75%. The mean length of hospital stay was 19.25 days, with a 30-day survival rate of 100%, without the need of reoperation or amputation. Reviewing the scientific literature available, we found no similar clinical experiences of optical spectrometry used as a method of measuring intraoperative perfusion of the ischemic extremity. Utilizing INVOS data to improve perfusion of periphery, we used minimal vasoactive support and restrictive bolus administration of intravenous fl uids with a satisfactory clinical outcome

Anesthesia of a child with open Botalli’s duct – a case report

Osmogodišnji dječak naručen je na elektivnu tonzilektomiju zbog ponavljanih upala srednjeg uha uzrokovanih hipertrofijom adenoida. Pacijent je imao otvoreni, tj. perzistentni arterijski duktus (engl. Persistent ductus arteriosus – PDA), čestu prirođenu srčanu grešku s očuvanom komunikacijom između aorte i plućne arterije. Kod pacijenta je postojao samo hemodinamski neznatan lijevo-desni pretok. Trenutačne smjernice za anesteziju pacijenata s lijevo-desnim pretokom uključuju: 1. održavanje ili smanjenje sustavnoga vaskularnog otpora (SVR) kao hemodinamski cilj; 2. izbjegavanje smanjenja plućnoga vaskularnog otpora (PVR); 3.izbjegavanje hiperoksije i hipokarbije. Predoperacijska obrada uključivala je suradnju s pedijatrijskim kardiologom koji je napravio procjenu pacijentova srčanog statusa, uključujući ultrazvuk srca i elektrokardiogram (EKG). Tijek anestezije protekao je bez neželjenih događaja. Nakon reverzije neuromuskularne blokade i ekstubacije pacijent je budan, hemodinamski stabilan i zadovoljavajućega respiratornog stanja prebačen u sobu za oporavak poslije anestezije. Preoksigenacija 100%-tnim kisikom prijeporna je u ovakvih pacijenata. Detaljna predoperacijska procjena srčanog statusa i izbjegavanje povećanja protoka kroz otvorenu komunikaciju ključni su za dobar ishod u pacijenata s PDA-om.The 8-year-old boy was scheduled for an elective tonsillectomy because of a recurring middle ear infection, caused by adenoid hypertrophy. The patient had a patent ductus arteriosus (PDA), a common congenital heart defect with a persistent communication between the aorta and the pulmonary artery. In this patient, there was only a haemodynamically insignificant left-to-right shunt. Current guidelines for anaesthetic management of patients with left-to-right shunt include: 1. Maintenance or decrease of systemic vascular resistance (SVR) as a haemodynamic goal; 2. Avoiding decreases in pulmonary vascular resistance (PVR); 3. Avoiding hyperoxia and hypocarbia. The preoperative assessment included collaboration with paediatric cardiologist who reevaluated the patient’s cardiac status, including a heart ultrasound and an ECG cardiography. The course of anaesthesia was uneventful. After neuromuscular blockade reversion and extubation, the patient was transferred to the post-anesthesia care unit (PACU) awake, haemodynamically stable and with satisfactory respiratory status. The preoxygenation with 100% oxygen is a source of controversy. In a patient with PDA, a thorough preoperative evaluation of cardiac status and avoidance of worsening left-to-right shunt are essential for good outcome

Ceftazidime/ Avibactam for Treatment of Intrahospital Ventilator-Associated Pneumonia in COVID-19 Patients

U razdoblju pandemije koronavirusne bolesti 2019. (COVID-19) mnogi bolesnici kojima je bila potrebna invazivna mehanička ventilacija, primljeni su u jedinice intenzivnog liječenja (JIL) zbog teškog respiratornog zatajenja povezanog s bolešću COVID-19. Prijam u JIL i invazivna mehanička ventilacija neovisni su rizici za pneumoniju povezanu s ventilatorom (engl. ventilator associated pneumonia; VAP), kod koje je zabilježena visoka stopa smrtnosti i dulji boravak u JIL-u te je produljeno bolničko liječenje. Ako govorimo o uzročnicima VAP-a, Pseudomonas aeruginosa bio je jedan od glavnih gram-negativnih nefermentirajućih uzročnika ove patologije, zajedno s Burkholderia cepacia i Stenotrophomonas maltophilia u manjoj mjeri. Protiv gram-negativnih mikroorganizama otpornih na karbapeneme, ceftazidim/avibaktam (CZA) jedan je od najčešće korištenih antimikrobnih lijekova. Cilj ovog preglednog članka bio je opisati korištenje CZA u liječenju bolesnika s infekcijom COVID-19 koji su razvili VAP uzrokovan P. aeruginosa, B. cepacia i S. maltophilia, usporediti to s podatcima objavljenim u literaturi te skrenuti pozornost na kontinuiranu primjenu lijeka kao drugačijeg modaliteta u odnosu na standardni način primjene u bolusu. Unatoč visokoj smrtnosti kritično oboljelih bolesnika s COVID-om, CZA predstavlja valjanu opciju liječenja VAP-a uzrokovanog nefermentirajućim gram-negativnim mikroorganizmima.In the period of the coronavirus diseFase 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to the intensive care unit (ICU) due to severe respiratory failure associated with COVID-19 infection. In fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with a high mortality rate and longer ICU and hospital stays. Pseudomonas aeruginosa was the first causative agent of this pathology (VAP), but rare non-fermenting Gram-negative microorganisms such as Burkholderia cepacea and Stenotrophomonas maltophilia have also emerged as potential etiological agents. One of the most frequently used antibiotics against carbapenem- resistant Gram-negative microorganisms is ceftazidime/avibactam (CZA). The aim of this review article was to describe the use of CZA in a series of cases of patients with COVID-19 infection who developed difficult-to-treat VAP due to P. aeruginosa, B. cepacea and S. maltophilia and to compare it with data published in the literature, as well as to draw attention to the continuous administration of the drug as a different modality compared to the standard method of bolus administration. Despite the high mortality of critically ill patients with COVID-19, CZA, especially in combination therapy, could represent a valid treatment option for VAP caused by non-fermenting Gram-negative microorganisms

Ceftazidime/ Avibactam for Treatment of Intrahospital Ventilator-Associated Pneumonia in COVID-19 Patients

U razdoblju pandemije koronavirusne bolesti 2019. (COVID-19) mnogi bolesnici kojima je bila potrebna invazivna mehanička ventilacija, primljeni su u jedinice intenzivnog liječenja (JIL) zbog teškog respiratornog zatajenja povezanog s bolešću COVID-19. Prijam u JIL i invazivna mehanička ventilacija neovisni su rizici za pneumoniju povezanu s ventilatorom (engl. ventilator associated pneumonia; VAP), kod koje je zabilježena visoka stopa smrtnosti i dulji boravak u JIL-u te je produljeno bolničko liječenje. Ako govorimo o uzročnicima VAP-a, Pseudomonas aeruginosa bio je jedan od glavnih gram-negativnih nefermentirajućih uzročnika ove patologije, zajedno s Burkholderia cepacia i Stenotrophomonas maltophilia u manjoj mjeri. Protiv gram-negativnih mikroorganizama otpornih na karbapeneme, ceftazidim/avibaktam (CZA) jedan je od najčešće korištenih antimikrobnih lijekova. Cilj ovog preglednog članka bio je opisati korištenje CZA u liječenju bolesnika s infekcijom COVID-19 koji su razvili VAP uzrokovan P. aeruginosa, B. cepacia i S. maltophilia, usporediti to s podatcima objavljenim u literaturi te skrenuti pozornost na kontinuiranu primjenu lijeka kao drugačijeg modaliteta u odnosu na standardni način primjene u bolusu. Unatoč visokoj smrtnosti kritično oboljelih bolesnika s COVID-om, CZA predstavlja valjanu opciju liječenja VAP-a uzrokovanog nefermentirajućim gram-negativnim mikroorganizmima.In the period of the coronavirus diseFase 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to the intensive care unit (ICU) due to severe respiratory failure associated with COVID-19 infection. In fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with a high mortality rate and longer ICU and hospital stays. Pseudomonas aeruginosa was the first causative agent of this pathology (VAP), but rare non-fermenting Gram-negative microorganisms such as Burkholderia cepacea and Stenotrophomonas maltophilia have also emerged as potential etiological agents. One of the most frequently used antibiotics against carbapenem- resistant Gram-negative microorganisms is ceftazidime/avibactam (CZA). The aim of this review article was to describe the use of CZA in a series of cases of patients with COVID-19 infection who developed difficult-to-treat VAP due to P. aeruginosa, B. cepacea and S. maltophilia and to compare it with data published in the literature, as well as to draw attention to the continuous administration of the drug as a different modality compared to the standard method of bolus administration. Despite the high mortality of critically ill patients with COVID-19, CZA, especially in combination therapy, could represent a valid treatment option for VAP caused by non-fermenting Gram-negative microorganisms

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following

Sequential Extracorporeal Blood Purification Is Associated with Prolonged Survival among ICU Patients with COVID-19 and Confirmed Bacterial Superinfection

Introduction: This study investigates the impact of sequential extracorporeal treatments with oXiris® or CytoSorb® plus Seraph-100® on the clinical and laboratory parameters of critically ill COVID-19 patients with bacterial superinfection. Methods: Patients admitted to the intensive care unit with COVID-19, bacterial superinfection, and undergoing blood purification (BP) were enrolled in this prospective, single-center, observational study. "standard BP" with oXiris® or CytoSorb® were used in 35 COVID-19 patients with bacterial infection. Seraph-100® was added in 33 patients when available serially in the same oXiris® circuit or as sequential treatment with CytoSorb® as a sequential BP. Results: A significant reduction in SOFA score 3 days after treatment was observed in patients undergoing sequential BP (11.3 vs. 8.17, p 0.05). The difference between the observed and expected mortality rate based on APACHE IV was greater in the sequential BP group (42.4% vs. 81.7%, p 0.05). Patients treated with sequential BP had a longer survival than those treated with "standard BP" (22.4 vs. 18.7 months; p < 0.001). Conclusions: The sequential approach may enhance the positive effect of BP on organ dysfunction among critically ill patients with COVID-19 and bacterial superinfection