SEPSIS IN SURGICAL PATIENT

Velike epidemiološke studije upućuju na veliku učestalost sepse u općoj populaciji. Usprkos napretku kirurgije, kirurški pacijenti sa sepsom čine gotovo trećinu svih slučajeva sepse. Sepsa je vodeći uzrok pobola i smrtnosti među kirurškim bolesnicima, a intrabdominalne infekcije glavno su izvorište sepse. Prema mišljenju nekih autora, sepsa u kirurških pacijenata razlikuje se od one u nekirurških zbog modulacije imunološke funkcije koja se javlja kao posljedica kirurškog zahvata i primijenjene anestezije te bi stoga te dvije skupine trebalo pratiti odvojeno. U liječenju sepse ključnu ulogu imaju rano prepoznavanje sepse, brza dijagnostika i agresivno liječenje koje uključuje i izbor intervencije s najmanjim fi ziološkim inzultom s ciljem kontrole izvora infekcije. Značajan naglasak treba staviti i na prevenciju sepse koja se provodi u svim dijelovima perioperacijskog razdoblja. Liječenje kirurškog septičnog bolesnika je kompleksno i zahtijeva multidisciplinarni pristup.Epidemiological studies indicate a large incidence of sepsis in the general population. Despite advances in surgery, surgical patients with sepsis make almost one-third of all cases of sepsis. Sepsis is the leading cause of morbidity and mortality among surgical patients, with intra-abdominal infection as the main source of sepsis. According to some authors, sepsis in surgical patients is different from those in non-surgical patients because of the immune function modulation that occurs as a result of surgery and anesthesia applied; therefore, these two groups should be monitored separately. In the treatment of sepsis, the key steps are early recognition of sepsis, rapid diagnosis, and aggressive treatment that includes the choice of intervention with the least physiological insult to control the sources of infection. Emphasis should be placed on the prevention of sepsis throughout the perioperative period. In surgical septic patients, treatment is complex and requires a multidisciplinary approach

SEPSIS IN SURGICAL PATIENT

Velike epidemiološke studije upućuju na veliku učestalost sepse u općoj populaciji. Usprkos napretku kirurgije, kirurški pacijenti sa sepsom čine gotovo trećinu svih slučajeva sepse. Sepsa je vodeći uzrok pobola i smrtnosti među kirurškim bolesnicima, a intrabdominalne infekcije glavno su izvorište sepse. Prema mišljenju nekih autora, sepsa u kirurških pacijenata razlikuje se od one u nekirurških zbog modulacije imunološke funkcije koja se javlja kao posljedica kirurškog zahvata i primijenjene anestezije te bi stoga te dvije skupine trebalo pratiti odvojeno. U liječenju sepse ključnu ulogu imaju rano prepoznavanje sepse, brza dijagnostika i agresivno liječenje koje uključuje i izbor intervencije s najmanjim fi ziološkim inzultom s ciljem kontrole izvora infekcije. Značajan naglasak treba staviti i na prevenciju sepse koja se provodi u svim dijelovima perioperacijskog razdoblja. Liječenje kirurškog septičnog bolesnika je kompleksno i zahtijeva multidisciplinarni pristup.Epidemiological studies indicate a large incidence of sepsis in the general population. Despite advances in surgery, surgical patients with sepsis make almost one-third of all cases of sepsis. Sepsis is the leading cause of morbidity and mortality among surgical patients, with intra-abdominal infection as the main source of sepsis. According to some authors, sepsis in surgical patients is different from those in non-surgical patients because of the immune function modulation that occurs as a result of surgery and anesthesia applied; therefore, these two groups should be monitored separately. In the treatment of sepsis, the key steps are early recognition of sepsis, rapid diagnosis, and aggressive treatment that includes the choice of intervention with the least physiological insult to control the sources of infection. Emphasis should be placed on the prevention of sepsis throughout the perioperative period. In surgical septic patients, treatment is complex and requires a multidisciplinary approach

Parvovirus B 19 (PVB19) Induced Pure Red Cell Aplasia (PRCA) in Immunocompromised Patient after Liver Transplantation

Presented here is a case of human parvovirus B19 (PVB19) induced pure red-cell aplasia (PRCA) in immunocompromised patient after orthotopic liver transplantation (OLT). PVB19 is a small, single-stranded DNA whose target cell is the erythroid progenitor in bone marrow. Manifestations of PVB19 infection vary with the immunologic status of the patient, ranging from asymptomatic to severe infections and PRCA. Post-transplant PRCA is induced either by immunosuppressive agents or PVB19. In the presented case, bone marrow aspiration characterized by the absence of mature erythroid precursors and detection of PVB19 DNA in blood led to treatment with high-dose intravenous human immunoglobulins (IVIG) and subsequent recovery of erythropoiesis. Due to insufficient antibody response in immunocompromised patients, suppression of the PVB19 infection is delayed and repetitive treatments may be administrated in attempt of reversing PRCA

Parvovirus B 19 (PVB19) induced pure red cell aplasia (PRCA) in immunocompromised patient after liver transplantation [Izolirana aplazija crvene krvne loze uzrokovana infekcijom Parvovirusom B 19 nakon transplantacije jetre]

Presented here is a case of human parvovirus B19 (PVB19) induced pure red-cell aplasia (PRCA) in immunocompromised patient after orthotopic liver transplantation (OLT). PVB19 is a small, single-stranded DNA whose target cell is the erythroid progenitor in bone marrow. Manifestations of PVB19 infection vary with the immunologic status of the patient, ranging from asymptomatic to severe infections and PRCA. Post-transplant PRCA is induced either by immunosuppressive agents or PVB19. In the presented case, bone marrow aspiration characterized by the absence of mature erythroid precursors and detection of PVB19 DNA in blood led to treatment with high-dose intravenous human immunoglobulins (IVIG) and subsequent recovery of erythropoiesis. Due to insufficient antibody response in immunocompromised patients, suppression of the PVB19 infection is delayed and repetitive treatments may be administrated in attempt of reversing PRCA

Epitheloid Hemangioendothelioma in Patient with Liver Transplantation

Malignant hepatic epithelioid hemangioendothelioma (HEH) is a rare malignant tumor of vascular origin with unknown aetiology and a variable natural course. At the time of diagnosis, most patients present with multifocal tumours lesions that involve both liver lobes. From the therapeutic aspect, liver resection (LRx), liver transplantation (LTx), chemotherapy, radiotherapy, and/or immunotherapy have been used in the treatment of patients with HEH. However, because of the rarity of this tumor and its unpredictable natural history, it is impossible to assess the effectiveness of these respective therapies. In this report, our objective was to present clinical aspects, diagnostic options, therapeutic modalities, and the clinical outcome of single patient with LTx because of this rare tumor

Perioperative volume replacement therapy for orthopic liver transplantation-observational, retrospective study

Cilj: Tijekom transplantacije jetre očekuju se značajni gubitci tjelesnih tekućina koje je potrebno nadoknaditi kristaloidnim i koloidnim otopinama te transfuzijom krvlju i krvnim derivatima. U studiji smo analizirali je li u petogodišnjem razdoblju promijenjen pristup intraoperacijskoj nadoknadi tekućina i krvnih derivata tijekom transplantacije jetre. Materijali i metode: U opservacijskoj retrospektivnoj studiji analizirali smo podatke ukupno 155 pacijenata kojima je transplantirana jetra u Kliničkoj bolnici Merkur, 79 tijekom 2015. godine i 76 tijekom 2010. godine. Analizirali smo ukupni gubitak krvi, ukupni uneseni volumen tekućina tijekom transplantacijskog postupka te volumen pojedinih vrsta tekućina (kristaloidi, koloidi, koncentrati eritrocita, svježe smrznuta plazma, trombociti). Statistička analiza rađena je Studentovim t-testom. Rezultati: Pacijenti su bili međusobno usporedivi po tjelesnoj masi i visini, MELD ljestvici. Ukupni gubitci krvi (ml) tijekom transplantacije jetre u 2015. i 2010. godini iznosili su: 6526± 4194 i 11122± 6685, P<0,001. Volumeni unesenih tekućina (ml) tijekom transplantacije jetre u 2015. i 2010. godini iznosili su: ukupni volumen tekućina 9640± 6017 i 18433 ± 7282, P< 0,001; kristaloidi 5077± 1443 i 5674± 2326, P=0,055; koloidi 1853± 814 i 2244± 1188, P=0,018; autologna krv 1097± 1160 i 1927± 2608, P=0,011; homologna krv 1293± 1247 i 2979± 2196, P<0,001; svježe smrznuta plazma 2244± 1523 i 5429± 1954, P<0,001; trombociti 349± 387 i 426± 313, P=0,176. Zaključci: Ovom studijom uočeno je značajno smanjenje ukupnog volumnog unosa, unosa koloidnih otopina, koncentrata eritrocita i svježe smrznute plazme tijekom transplantacije jetre u razdoblju od pet godina. Razlozi navedenog su ograničavanje perioperacijske volumne nadoknade u svrhu smanjivanja nepovoljnih učinaka volumnog preopterećenja. Ipak, najvažniji je faktor anestezijsko i kirurško iskustvo prikupljeno tijekom niza uspješnih godina u transplantacijskoj medicini.Aim: Significant fluid losses occur during liver transplantation, which need to be replaced. In this study, we analyzed whether fluid replacement strategies during liver transplantation have changed over a five-year period. Materials and Methods: In this observational, retrospective study, we collected data on 155 patients who underwent liver transplantation at the University Hospital «Merkur», 79 in 2015 and 76 in 2010. We analyzed total blood loss, total volume of replaced fluids and the volume of crystalloids, colloids, erythrocyte concentrates, fresh frozen plasma and platelets applied. We employed the Student t-test for statistical analysis. Results: Total blood losses (ml) in 2015 and 2010 were: 6526± 4194 and 11122± 6685, respectively, P<0,001. Volumes of replaced fluids (ml) in 2015 and 2010 were following: total fluid volume 9640± 6017 and 18433± 7282, P< 0,001; crystalline 5077± 1443 and 5674± 2326, P=0,055; colloids 1853± 814 and 2244± 1188, P=0,018 ; autologous blood 1097± 1160 and1927± 2608, P=0,011; homologous blood 1293± 1247 and 2979± 2196, P<0,001; fresh frozen plasma 2244± 1523 and 5429± 1954, P<0,001; platelets 349± 387 and 426± 313, P=0,176. Conclusions: This study showed a significant reduction in total fluid replacement, as well as in replacement of colloids, blood transfusion and fresh frozen plasma during liver transplantation over a period of five years. A possible explanation is a more restrictive perioperative fluid replacement strategy employed with the aim of reducing adverse effects of volume overload as well as a growing experience acquired over a number of successful years in transplantation medicine

Spinal Anesthesia at the L2–3 and L3–4 Levels: Comparison of Analgesia and Hemodynamic Response

Aim of this study was to evaluate level of analgesia and hemodynamic response to spinal anesthesia obtained by administering 15 mg 0.5% isobaric bupivacaine at L2–3 vs. L3–4 interspace for inguinal herniorrhaphy, since studies comparing analgesia and hemodynamic response at the L2–3 vs. L3–4 interspaces are lacking. In a prospective, randomized clinical study that encountered 72 patients undergoing elective inguinal herniorrhaphy randomly allocated in to two equal groups L2–3 (N=36) and L3–4 (N=36) according to lumbar interspace where intrathecal injection of bupivacaine was administered. Analgesia was evaluated by intraoperative »rescue« fentanyl requirements, the absence of pain and the maximal visual analogue scale (VAS) scores reached per patient during the operation. The severity of intraoperative pain was quantified by a 10 cm VAS scale (VAS 0: no pain to 10: worst pain imaginable) every 5 minutes after skin incision until the end of the operation. VAS>3 was treated with intravenous fentanyl 25 μg. Hemodynamic response was monitored and evaluated, heart rate was continuously monitored as well as, baseline systolic, diastolic and mean arterial pressure prior to induction and every 5 minute after applying spinal anesthesia until surgical completion. Intraoperative fentanyl requirements were significantly higher in group L3–4 (L2–3 0%, 97.5% confidence interval [CI] 0.0–0.11 vs. L3–4 17%, 95% CI 0.07–0.32, p=0.025). Absence of pain was significantly higher in L2–3 group at the beginning of the operation (L2–3 89%, 95% CI 0.74–0.96 vs. L3–4 67%, 95% CI 0.50–0.79, p=0.047). The maximal VAS scores reached per patient during the operation in L2–3 group were lower then in L3–4 group (L2–3 median [M] 0, range [R] 0–3, L3–4 M 0, R 0–8, p=0.014). There were no significant differences (p>0.05) in the incidence of hypotension (L2–3 19%, 95% CI 0.09–0.35 vs. L3–4 17%, 95% CI 0.07–0.32) and bradycardia (L2–3 19%, 95% CI 0.09–0.35 vs. L3–4 8%, 95% CI 0.02–0.23). Spinal anesthesia with isobaric bupivacaine administered in L2–3 interspace for inguinal herniorrhaphy provides superior analgesia and equal hemodynamic stability as compared to neuroaxial anesthesia administered in the L3–4 interspace

BLOODSTREAM INFECTIONS AFTER LIVER AND HEMATOPOIETIC STEM CELL TRANSPLANTATION

Cilj ovog retrospektivnog istraživanja je ustanoviti i usporediti incidenciju, vrijeme pojavnosti kao i etiologiju infekcija krvotoka u bolesnika liječenih ortotopnom transplantacijom jetre (OTJ) ili transplantacijom krvotvornih matičnih stanica (TKMS), na temelju iskustva jedne ustanove. Analizirano je 280 uzastopnih transplantacija u vremenskom razdoblju od 34 mjeseca. Zabilježene su 84 epizode infekcija krvotoka (47 kod OTJ bolesnika, 37 kod TKMS bolesnika) s medijanom nastupa 28 dana nakon transplantacije. Relativna incidencija infekcija krvotoka iznosila je 34,6 (OTJ) i 29,4 (TKMS) epizoda na 100 bolesnika, te nije uočena statistički značajna razlika između skupina (p=0,52). Infekcije krvotoka su se u TKMS bolesnika javile značajno ranije (p=0,003), nego u OTJ bolesnika. Ovo je istraživanje potvrdilo nedavno objavljene podatke o povratku gram-negativnih patogena kao glavnih uzročnika infekcija krvotoka: gram-negativni bacili predominantno su izolirani u OTJ bolesnika, gdje su bili odgovorni za 58,5% slučajeva infekcija krvotoka, a učestalo su izolirani (39%) i kod TKMS bolesnika. Mikrobiološki izolati iz skupine bolesnika s transplantiranom jetrom pokazali su višu incidenciju rezistentnih enterobakterija koje proizvode beta-laktamaze proširenog spektra (ESBL) u usporedbi s izolatima bolesnika s transplantacijom krvotvornih matičnih stanica. P. aeruginosa bio je najkompliciraniji mikroorganizam za liječenje u obje skupine s obzirom da je rezistencija na karbapeneme ovog uzročnika iznosila 57% kod OTJ i 44% kod TKMS. U zaključku, infekcije krvotoka su važne komplikacije nakon ortotopne transplantacije jetre, kao i transplantacije krvotvornih matičnih stanica. Nadzor i analiza mikroorganizama koji uzrokuju infekcije krvotoka i druge ozbiljne infektivne komplikacije u transplantiranih bolesnika ostaje glavni preduvjet za planiranje intervencija vezanih uz liječenje infekcija u tih bolesnika.The aim of this retrospective study was to evaluate and compare the incidence, timing and etiology of bloodstream infections (BSIs) in patients treated with liver- (LT) or hematopoietic stem cell transplantation (HSCT) in a single institution. We evaluated 280 consecutive transplantations over a period of 34 months. Our results demonstrated 84 episodes of BSIs (47 in LT patients and 37 in HSCT patients) at a median of 28 days post-transplantation. Relative incidence of 34.6 and 29.4 BSI episodes per 100 LT and HSCT patients, respectively, did not differ significantly between the two groups (p=0.52). BSIs in HSCT patients occurred significantly earlier (p=0.003) than in LT patients. The recently described reemergence of gram-negative (GN) pathogens as causative agents of BSIs in these patients was confirmed: GN bacilli were the predominant isolates in the LT group, responsible for 58.5% of BSIs and a very frequent (39%) cause of BSIs in the HSCT group. A higher incidence of resistant enterobacteriaceae producing extended spectrum beta-lactamases was found in isolates from LT patients compared to HSCT patients. In both groups, Pseudomonas aeruginosa was the most difficult to treat organism, with 57% of these isolates in LT patients and 44% in HSCT patients being resistant to carbapenems. To conclude, BSIs were confirmed to be important infectious complications of both LT and HSCT. Surveillance and analysis of bacteria causing bloodstream and other serious infections in transplanted patients remain the main prerequisites for planning interventions regarding prevention and treatment of infections in these patient

Viscoelastic hemostatic tests during liver transplantation – have we changed blood transfusion therapy?

Uvod: Transplantacija ili presađivanje jetre jest priznata metoda liječenja kojom se terminalno bolesna jetra zamjenjuje sa zdravom jetrom darivatelja. Standardni laboratorijski testovi (protrombinsko vrijeme, aktivirano parcijalno tromboplastinsko vrijeme, fibrinogen, antitrombin), premda koreliraju s težinom jetrene bolesti, pokazali su inferiornost u odnosu na viskolelastične testove (trombelastogram – TEG i rotacijska trombelastometrija – ROTEM) u procjeni funkcije koagulacijskog sustava u terminalnoj fazi jetrene bolesti. Cilj ovog istraživanja bio je utvrditi na koji je način intraoperacijska upotreba viskolestičnih testova u procjeni hemostaze tijekom transplantacije jetre utjecala na transfuzijsko liječenje u Kliničkoj bolnici Merkur. Metode: Ovom retrospektivnom, opservacijskom studijom analizirane su slijedeće varijable za 76 pacijenta iz 2010. (bez ROTEM-a) te 82 pacijenta iz 2021. (s ROTEM-om) kojima je u KB Merkuru transplantirana jetra : intraoperacijska nadoknada tekućinama (kristaloidne, koloidne otopine); transfuzijsko liječenje krvnim derivatima (deplazmatizirani koncentrati eritrocita, svježe smrznuta plazma, trombociti, krioprecipitat); ukupni intraoperacijski gubitci (krv, diureza, međustanični prostor); ukupna nadoknada tekućinama i krvnim derivatima. Rezultati: Tijekom 2010. prosječna ukupna nadoknada tekućinama i krvnim derivatima bila je 18 433 ml dok je za 2021. bila 9838 ml (p<0,0001). Prosječni volumen kristaloidnih otopina ordiniranih 2010. tijekom transplantacije jetre bio je 5674 ml dok je 2021. bio 4734 ml (p=0,0015); koloidnih 2010. godine 2244 ml, a koloidnih 2021. godine 1949 ml (p=0,07). Prosječna količina deplazmatiziranih eritrocita ordinirana 2010. bila je 2927 ml dok je 2021. bila 1266 ml (p<0,0001). Prosječna količina svježe smrznute plazme, trombocita i krioprecipitata ordiniranih 2010. bila je 5428, 426, 266 ml dok je 2021. bila 823 (p<0,0001), 137 (p<0,0001), 366 ml (p<0,03). Zaključak: Uporabom viskoelastičnih testova za praćenje hemostaze tijekom transplantacije jetre značajno je smanjeno davanje svih krvnih derivata, osim krioprecipitata čija potrošnja je povećana, a nije utjecala na količinu ordiniranih koloidnih otopina. Smanjenje količine krvnih derivata je od iznimnog značaja s obzirom na rizike koje nosi transfuzijsko liječenje.Introduction: Liver transplantation is a viable treatment for end stage liver desease in which a terminally ill liver is replaced with a healthy donor liver. Standard laboratory tests (prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin), although correlates with the severity of liver disease, showed inferiority to viscolelastic tests (thrombelastogram – TEG, rotational thrombelastometry – ROTEM) in the assessment of coagulation in the end stage liver desease. The aim of this study was to determine if the intraoperative use of viscolastical tests during liver transplantation have influenced amount of administered blood products. Methods: This retrospective, observational study analyzed the following variables for 76 patients in 2010. (without ROTEM) and 82 patients in 2021. (with ROTEM) who underwent liver transplantation at University Hospital Merkur: intraoperative fluid replacement (crystalloid, colloid); blood products (deplasmatized erythrocytes, fresh frozen plasma, platelets, cryoprecipitate); total intraoperative fluide losses (blood, diuresis, intercellular space); total compensation of fluids and blood products. Results: In 2010. the average total compensation of fluids and blood products was 18,433 ml, while in 2021. it was 9,838 ml (p <0.0001). Volume of crystalloids administered in 2010. was 5674 ml, in 2021. 4734 ml (p = 0.0015); colloids in 2010. 2244 ml, in 2021. 1949 ml (p = 0.07). Deplasmated erythrocytes administered in 2010. were 2927 ml while in 2021. 1266 ml (p <0.0001). Fresh frozen plasma, platelets and cryoprecipitates administered in 2010. were 5428, 426, 266 ml, in 2021. it was 823 (p <0.0001), 137 (p <0.0001), 366 ml (p <0, 03). Conclusion: The use of viscoelastic tests to monitor hemostasis during liver transplantation significantly reduced the administration of all blood products, except cryoprecipitates whose consumption was increased and did not affect the amount of administered colloids. Reducing the amount of blood products is important given the risks related to transfusion of blood products