MANAGEMENT OF ADULT SEPTIC PATIENT IN EMERGENCY UNIT

Pravodobna identifi kacija bolesnika sa sepsom je od krucijalnog značenja za ishod bolesnika. Od osobite je važnosti nadoknada tekućine. Stanje većine bolesnika zahtijeva agresivnu nadoknadu tekućine što je moguće ranije, odnosno tijekom prvih 24 sata liječenja počevši s brzim opterećenjem tekućinom zbog izražene teške hipovolemije. Otopine u dozi od >1000 mL kristaloida ili 300-500 mL koloida tijekom 30 minuta uz praćenje hemodinamskog stanja bolesnika i određivanje hitnog laboratorijskog panela (prije samog prijma) su prvi terapijski odabir. Prikazujemo slučaj starijeg bolesnika sa sepsom koji je imao akutno oštećenje bubrežne funkcije (AOBF) uzrokovano sepsom, povezano s produljenom hospitalizacijom i povećanim troškovima njege i liječenja no uz dobar klinički odgovor zbog pravodobnog terapijskog pristupa.Early identifi cation of sepsis is crucial to improve patient outcomes. Yet, sepsis can be diffi cult to differentiate in Emergency Unit. Sepsis treatment includes fl uid resuscitation as soon as possible, starting with >1000 mL of crystalloids or 500 mL of colloids for 30 min. Acute kidney injury is a serious complication of sepsis, associated with increased mortality, prolonged hospital stay and increased cost of care. In patients with sepsis, it would be useful to have some biomarkers of early organ damage, to improve the capacity for early recognition and diagnosis of acute kidney injury

MANAGEMENT OF ADULT SEPTIC PATIENT IN EMERGENCY UNIT

Pravodobna identifi kacija bolesnika sa sepsom je od krucijalnog značenja za ishod bolesnika. Od osobite je važnosti nadoknada tekućine. Stanje većine bolesnika zahtijeva agresivnu nadoknadu tekućine što je moguće ranije, odnosno tijekom prvih 24 sata liječenja počevši s brzim opterećenjem tekućinom zbog izražene teške hipovolemije. Otopine u dozi od >1000 mL kristaloida ili 300-500 mL koloida tijekom 30 minuta uz praćenje hemodinamskog stanja bolesnika i određivanje hitnog laboratorijskog panela (prije samog prijma) su prvi terapijski odabir. Prikazujemo slučaj starijeg bolesnika sa sepsom koji je imao akutno oštećenje bubrežne funkcije (AOBF) uzrokovano sepsom, povezano s produljenom hospitalizacijom i povećanim troškovima njege i liječenja no uz dobar klinički odgovor zbog pravodobnog terapijskog pristupa.Early identifi cation of sepsis is crucial to improve patient outcomes. Yet, sepsis can be diffi cult to differentiate in Emergency Unit. Sepsis treatment includes fl uid resuscitation as soon as possible, starting with >1000 mL of crystalloids or 500 mL of colloids for 30 min. Acute kidney injury is a serious complication of sepsis, associated with increased mortality, prolonged hospital stay and increased cost of care. In patients with sepsis, it would be useful to have some biomarkers of early organ damage, to improve the capacity for early recognition and diagnosis of acute kidney injury

Endokarditis nativne valvule uzrokovan meticilin-rezistentnim sojem bakterije Staphylococcus epidermidis u bolesnika s uznapredovalom cirozom jetre

We present a case of a 50-year-old man with advanced liver cirrhosis and native valve infective endocarditis caused by methicillin-resistant Staphylococcus epidermidis. Bacterial infections are one of the most common complications of liver cirrhosis, but reports of infective endocarditis in patients with liver cirrhosis are relatively rare. Because of vulnerability of patients with advanced cirrhosis for developing infections, it is necessary to pay attention to the pathogens that are sometimes considered contamination and actively seek for the seat of infection, even in less expected areas (e.g., native heart valves without a history of heart disease).Prikazujemo slučaj 50-godišnjeg muškarca s uznapredovalom cirozom jetre i endokarditisom nativne valvule uzrokovane meticilin rezistentnim sojem bakterije Staphylocoocus epidermidis. Bakterijske infekcije jedne su od najčešćih komplikacija ciroze jetre, ali su slučajevi infektivnog endokarditisa u bolesnika s cirozom jetre relativno rijetki. Zbog osjetljivosti bolesnika s uznapredovalom cirozom za razvoj infekcija potrebno je obratiti pozornost i na patogene koje ponekad smatramo kontaminacijom te aktivno tražiti mjesto infekcije, čak i u manje očekivanim područjima (kao što su nativne srčane valvule bez povijesti ranije srčane bolesti)

Femoral nerve block- or intravenous- guided patient control analgesiafor early physical rehabilitation after anterior cruciate ligament reconstruction in "fast-track" orthopedics: what is optimal?

Background and purpose: "Fast-track" orthopaedics characterizes early start of physical rehabilitation (PHR). Quality of mobilization depends on pain therapy success and preservation of motor function and muscle strength. Patient-control-analgesia (PCA), as an upgrade of continuous intravenous (IV) or regional analgesia (FB) makes the modern base in treatment of acute pain. The aim of the study was to determine more effective post-operative PCA-analgesia (IV-PCA vs. FB-PCA) for early PHR in "fast-track" orthopaedics. Materials and Methods: Prospective, observer-blinded study included 40 adults (bought gender, ASA I/II) scheduled for anterior cruciate ligament reconstruction (RACL). Spinal anaesthesia (12.5 mg, 0.5% levobupivacaine; G27-Pencil-Point) was performed in all patients. Patients were divided in two equal groups. In Group IV-PCA intravenous (fentanyl 0.5-1μg kg–1h–1), and in Group FB-PCA regional (femoral block: 0.125% levobupivacaine, 8 ml h–1) PCA-analgesia (Group IV-PCA: fentanil 10μg/8min/x6max; Group FB-PCA: 0.125% levobupivacaine, 8ml/30min/x3max) was established after surgery. Pain score (VAS) was assessed during 24-hours and accepted as satisfactory by 3. Diclofenac 75 i.v. was given in two doses, immediatelly and 12 hours after surgery. Paracetamol 1g was added intravenously if VAS was ³ 4. Start of early PHR was planned six hours after surgery. Result: FB- and IV-PCA provided equally effective analgesia during first 24-hours after RACL (VAS3). Early PHR was possible 6-hours after surgery in 85% of Group FB-PCA (Group IV-PCA=20%) (P=0,0001) due to significantly lower VAS 0,7+/–0,2 (Group IV-PCA=3,0+/–0,2)(P<0,0001). Residual motor block, presented in three patient (15%) with FB-PCA, disabled the onset of PHR.Additional analgesic dose wasmore need inGroup IV-PCA(40%) (Group FB-PCA=10%) (P<0,0001). Conclusion: FB-PCA allows more successful pain-free early PHR for orthopaedics "fast-track" ACL reconstruction compare to IV-PCA, excluding 15% of the FB-PCA patients in whom residual muscle weakness was present

SOMETHING ABOUT DEFINITION AND EPIDEMIOLOGY OF SEPSIS

Učestalost sepse raste ali je zahvaljući naporima kampanja i razvoju smjernica za liječenje sepse došlo do smanjenja smrtnosti. Ipak, ukupni se broj umrlih zbog sepse čak i povećava, jer veći broj ljudi obolijeva. Sepsu treba smatrati hitnim stanjem, gotovo usporedivo s akutnim srčanim infarktom. S obzirom na veliku učestalost i visoku smrtnost jako je važno defi niciju sepse pokušati poboljšati. Definicija je važna i radi potrebe različitih istraživanja kao i aplikacije rezultata istraživanja u praksi. U siječnju 2014. tijekom 43. kongresa društva intenzivne medicine u San Francisku započelo se radom na novoj defi niciji. Vjerojatno bi nova defi nicija sepse bila ono što se danas podrazumijeva pod teškom sepsom. Planira se da će ta nova definicija vjerojatno biti dovršena tijekom 2015. godine.The prevalence of sepsis continues to increase, although, thanks to the efforts of the campaigns and the development of guidelines for sepsis treatment, the fatality rates have diminished, however, the sepsis total mortality is growing due to increased morbidity. Sepsis should be considered as an emergency almost similar to acute myocardial infarction. With regard to the high prevalence and high mortality rate, it is important to improve the defi nition of sepsis. This defi nition is also important in different researches, as well as in the application of the results in daily practice. In January 2014, at the 43rd Annual Congress of Society of Critical Care Medicine in San Francisco, the work on establishing a new defi nition of sepsis was started. New defi nition of sepsis probably would represent what is known today as severe sepsis. The new defi nition could probably be accomplished during 2015

SOMETHING ABOUT DEFINITION AND EPIDEMIOLOGY OF SEPSIS

Učestalost sepse raste ali je zahvaljući naporima kampanja i razvoju smjernica za liječenje sepse došlo do smanjenja smrtnosti. Ipak, ukupni se broj umrlih zbog sepse čak i povećava, jer veći broj ljudi obolijeva. Sepsu treba smatrati hitnim stanjem, gotovo usporedivo s akutnim srčanim infarktom. S obzirom na veliku učestalost i visoku smrtnost jako je važno defi niciju sepse pokušati poboljšati. Definicija je važna i radi potrebe različitih istraživanja kao i aplikacije rezultata istraživanja u praksi. U siječnju 2014. tijekom 43. kongresa društva intenzivne medicine u San Francisku započelo se radom na novoj defi niciji. Vjerojatno bi nova defi nicija sepse bila ono što se danas podrazumijeva pod teškom sepsom. Planira se da će ta nova definicija vjerojatno biti dovršena tijekom 2015. godine.The prevalence of sepsis continues to increase, although, thanks to the efforts of the campaigns and the development of guidelines for sepsis treatment, the fatality rates have diminished, however, the sepsis total mortality is growing due to increased morbidity. Sepsis should be considered as an emergency almost similar to acute myocardial infarction. With regard to the high prevalence and high mortality rate, it is important to improve the defi nition of sepsis. This defi nition is also important in different researches, as well as in the application of the results in daily practice. In January 2014, at the 43rd Annual Congress of Society of Critical Care Medicine in San Francisco, the work on establishing a new defi nition of sepsis was started. New defi nition of sepsis probably would represent what is known today as severe sepsis. The new defi nition could probably be accomplished during 2015

Hereditary angioedema type I in a female patient: a case report

Hereditary angioedema (HAE) is rare autosomal dominant disease, characterised by spontaneous and recurrent swellings in various parts of the body. The main inflammatory factor in HAE is bradykinin (a key mediator of non-allergic angioedema) and it is responsible for capillary leak. C1 esterase inhibitor (C1-INH) is a protease inhibitor that blocks the activation of the classic complement pathway, but there are also many others biochemical pathways, including kinin. Type I HAE is defined by low plasma levels of a normal C1 inhibitor (C1-INH). Case presentation. A 34-year-old female patient presented to the hospital complained of swollen and painful legs, flatulence, palpebral and labial edema, dyspnea, dysuria, frequent herpetic infections of mouth and nose, subfebrile body temperature and was hoarse. Over the last 20 years she suffered from occasional edemas of the extremities and abdomen. Laboratory testing showed a reduced level of C1-INH, and with other test results normal we diagnosed the patient with HAE type I. For emergency situations, we prescribed icatibant (B2 bradykinin receptor antagonist) subcutaneously. Individuals with HAE report episodic attacks during childhood that become more severe during adolescence. There is nonpitting edema in 3 predisposed places : subcutaneous tissue, the abdomen and the larynx. Edemas amplify during 12-24 hours and disappear during 3-5 days, with migrations to other locations. Treatment can be prophylactic, for acute attacks (icatibant) and before medical treatments. HAE is a potentially lethal disease and should be considered if repeating edema of various body parts, painful swelling and tightening of the skin are present

Thoughts and level of knowledge about palliative care among nursing students in Dubrovnik

Uvod: Palijativna skrb (PS) još je uvijek velika nepoznanica, kao i samom značenje te riječi. Danas, nakon što se pojam PS u medicini već desetak godina aktivno upotrebljava u našoj zemlji, možemo reći da je neznanja još uvijek dosta kako među zdravstvenim djelatnicima tako i u ostaloj populaciji. Sam naziv nosi „stigmu” uzrokovanu nedovoljnim znanjem i edukacijom. Upravo edukacija predstavlja ključni element u aktivnijoj primjeni resursa PS-a u svim fazama bolesti, kod bolesnika kojima je takva skrb potrebna. PS je i sveobuhvatna skrb primjerena teško oboljelom pacijentu čije se potrebe prepoznaju i uklanjaju multidisciplinarnim i holističkim pristupom. Cilj ovog istraživanja bio je utvrditi znanja i stavove studenata sestrinstva o palijativnoj skrbi te ustanoviti u kolikoj mjeri njihova dob, edukacija te iskustvo ili radno mjesto imaju utjecaja na njihovo razmišljanje o palijativnoj skrbi. Metode istraživanja: Istraživanje je provedeno dobrovoljnom i anonimnom anketom studenata na preddiplomskom i diplomskom studiju sestrinstva pri Sveučilištu u Dubrovniku. U anketu su bili uključeni studenti u radnom odnosu i nezaposleni studenti te studenti zdravstvene i nezdravstvene struke. Mjerni instrument primijenjen u ovom presječnom istraživanju bio je standardizirani upitnik PCQN (Palliative Care Quiz for Nurses). Upitnik sadrži 20 pitanja koja se odnose na filozofiju palijativne skrbi, kontrolu boli i pridruženih simptoma bolesti te psihičku, duhovnu i socijalnu problematiku PS-a. Ponuđeni odgovori na pitanja bili su: točno, netočno i ne znam. Točan odgovor bio je bodovan jednim bodom, dok su odgovori ne znam i netočno analizirani kao nula bodova. U statističkoj analizi primijenjena je analiza varijance (ANOVA) uz Kruskal-Wallisov i Mann Whitneyjev U-test. Rezultati: Većina ispitanika smatrala je da je dobro što se danas u izvedbeni plan studija uveo predmet Palijativna skrb (55,4 %). Nijedan student nije točno odgovorio na više od 12 pitanja, što u usporedbi s istovrsnim studijama drugih autora ukazuje na činjenicu da među našim ispitanicima postoji temeljno znanje.Introduction: Palliative care (PC) is still a big unknown. Today, after about 10 years of active use of this term in our country, a lack of knowledge is still quite common, both among health professionals and in the rest of the population. The term itself bears a “stigma” caused by insufficient knowledge and education. It is education that is the key element in the more active use of PC resources in all stages of the disease in patients who need such care. PC is a comprehensive care appropriate for a seriously ill patient whose needs are recognized and met using a multidisciplinary and holistic approach. The aim of this study was to determine the knowledge and attitudes of nursing students about palliative care and to determine the extent to which their age, education, and experience or occupation have an impact on their thinking about palliative care. Research methods: The study was conducted using a voluntary and anonymous survey of students at the undergraduate and graduate levels of study of Nursing at the University of Dubrovnik. The survey included employed and unemployed students, and students from both medical and non medical professions. The measuring instrument used in this study was a standardized PCQN (Palliative Care Quiz for Nurses) questionnaire. The questionnaire contains 20 questions related to the philosophy of palliative care, control of pain and associated disease symptoms, and psychological, spiritual, and social issues of PC. The possible answers were “correct”, “incorrect”, and “I do not know”. Correct answers were awarded one point while incorrect answers and the answer “I do not know” were awarded zero points. The statistical analysis used the analysis of variance (ANOVA) along with the Kruskal Wallis and Mann-Whitney U test. Results: The majority of respondents thought that it was good that a course on PC has been introduced into the study plan (55.4%). No student provided more than 12 correct answers. A comparison with similar studies shows that the respondents have a basic level of knowledge

Idiopathic hypoparathyreoidism, reversible cardiomyopathy and nephrogenic diabetes insipidus - case report

We are presenting a case of a 36-year-old patient with idiopathic hypoparathyroidism and reversible dilated cardiomyopathy as a result of hypocalcaemia. Twelve years later, the patient presented a picture of nephrogenic diabetes insipidus, which according to available literature has so far not yet been described

Minimally invasive procedures in diagnosis of low back and radicular pain

Križobolja i lumboishijalgija su značajni zdravstveni problemi današnjice. Bolesnici s navedenim tegobama često izostaju s posla, a troškovi operacijskog liječenja iznimno su visoki. Adekvatna dijagnostika križobolje i lumboishijalgije podrazumijeva detaljno poznavanje anatomije kralježnice i živčanih struktura, kao i rukovanje pomičnim RTG uređajem. Svrha je ovih procedura primjenom kratkodjelujućeg lokalnog anestetika anestezirati pojedine živčane završetke, a u slučaju provokativne diskografije provocirati bol, kako bi se sa sigurnošću potvrdilo koje su anatomske strukture uzrok bolova. To je potrebno stoga što križobolju mogu uzrokovati različite bolesti kralježnice. Najčešće su degenerativne promjene u intervertebralnom disku, promjene malih zglobova, oštećeni sakroilijakalni zglob ili hernijacija diska. Shodno ovome, a ovisno o različitim anatomskim strukturama koje mogu biti izvor bolova, postoji više dijagnostičkih minimalno invazivnih procedura. Svaka dijagnostička procedura, s kojom se egzaktno utvrdi uzrok križobolje ili lumboishijalgije, bolesnika posljedično potvrđuje kao dobrog kandidata za minimalno invazivni terapijski zahvat.Low back and radicular pain make a significant health concern. They are also one of the leading, medically related, causes for missed work. Furthermore, expenses for surgery are often very high. Adequate diagnosis of low back and radicular pain involves detailed knowledge of the anatomy of the lumbar spine and the nerve structures, as well as handling with C-arm. The purpose of these procedures, with the use of short-acting local anesthetic, is to anesthetize specific nerve endings in order to verify which anatomical structures are true pain generators. This is important because low back pain can be caused by vast palette of spine disorders. The most common include degenerative intervertebral disc disease, changes in the zygapophyseal (facet) joints, damaged sacroiliac joint or disc herniation. Depending on the different anatomical structures that can cause the low back and radicular pain, one can use several minimally invasive diagnostic procedures. Each minimally invasive diagnostic procedure, with which we confirm the exact cause of low back pain or radicular pain, consequently predisposes patients for minimally invasive therapeutic intervention