Donacija organa bolesnika s bakterijskim meningoencefalitisom – prvi slučaj u Hrvatskoj

The growing number of patients with terminal organ failure waiting for transplantation and the limited number of available organs demand that explantation teams see braindead patients with infectious diseases such as bacterial meningoencephalitis as potential donors, although until recently organ explantation from such donors has been contraindicated. This paper presents the first case of successful organ explantation from a donor with confirmed bacterial meningoencephalitis in our country. In this previously healthy patient (only with mild arterial hypertension in personal history), bacterial meningoencephalitis caused fulminant worsening and he deteriorated from mild disorder of consciousness (GCS 12) to brain death within only 24 hours. After the transplantation of organs was performed (heart, kidneys, liver and corneas were explanted), antibiotic therapy was continued in all organ recipients and two days after the transplantation none of the recipients showed any signs of infectious complications. This paper proves that this type of patients should also be treated as potential donors, under condition of appropriate microbiological diagnosis, antibiotic therapy and sustained hemodynamic stability, which should enlarge the number of organs available for transplantation.Sve veći broj bolesnika s terminalnim zatajenjem organa koji čekaju na presađivanje organa i ograničeni broj dostupnih organa nalažu da timovi za eksplantaciju razmatraju moždano mrtve bolesnike infektivnim bolestima kao što je bakterijski meningoencefalitis kao potencijalne donore organa, iako je eksplantacija organa kod takvih donora donedavno bila kontraindicirana. Ovdje se prikazuje prvi slučaj uspješne eksplantacije organa kod donora s potvrđenim bakterijskim meningoencefalitisom u našoj zemlji. Bolesnik je prethodno bio zdrav (samo s blagom arterijskom hipertenzijom u anamnezi), ali je meningoencefalitis uzrokovao veoma naglo pogoršanje koje je od blažeg poremećaja svijesti (Glasgowska ljestvica za komu, GCS 12) dovelo do moždane smrti u samo 24 sata. Nakon transplantacije organa (eksplantirani su srce, bubrezi, jetra i rožnice) nastavilo se s antibiotskom terapijom kod svih primatelja organa i dva dana nakon presađivanja nijedan od primatelja organa nije imao nikakvih znakova infektivnih komplikacija. Ovaj rad pokazuje kako se ove bolesnike treba isto tako smatrati potencijalnim donorima, uz primjerenu mikrobiološku dijagnostiku, antibiotsku terapiju i održavanje hemodinamske stabilnosti, čime bi se povećao broj organa dostupnih za presađivanje

Recombinant factor Vlla therapy in a patient on long term anticoagulant treatment with a bleeding and acute subdural hematoma

In this paper we report on the successful correction of a coagulopathy with activated recombinant factor seven (rFVIIa) therapy which enabled surgical removal of a life threatening subdural hematoma. The severe coagulopathy developed due to long term warfarin therapy, which followed heart valvular reconstruction and replacement. The coagulopathy failed to improve following fresh frozen plasma and vitamin K therapy. Activated recombinant factor VII therapy became the treatment of choice, which enabled the life saving surgical removal of the subdural hematoma

Anestezija kod operacijskog zahvata na hipofizi

Pituitary tumors account for more than 10% of all intracranial tumors. They often present with symptoms of hormonal hypersecretion, although they may also cause hypopituitarism. Transsphenoidal pituitary surgery has become a commonly performed neurosurgical procedure, which has certain challenges for the anesthesiologist due to many distinct comorbidities associated with various adenomas. This article provides a review of perioperative concerns regarding transsphenoidal pituitary surgery, encountered in a number of these patients. Thorough understanding of preoperative assessment, intraoperative management and potential complications is fundamental for successful perioperative patient care and avoidance of morbidity and mortality.Tumori hipofize čine više od 10% svih intrakranijskih tumora. Oni se često manifestiraju simptomima hipersekrecije hormona, ali mogu isto tako izazvati hipopituitarizam. Transsfenoidna kirurgija hipofize postala je čest neurokirurški zahvat koji pred anesteziologa postavlja stanovite izazove zbog mnogih istodobno postojećih bolesti udruženih s raznim adenomima. Ovaj članak daje pregled pitanja koja treba razmotriti prije pristupanja transsfenoidnoj kirurgiji hipofize u većine ovih bolesnika. Potpuno razumijevanje prijeoperacijske procjene, intraoperacijskog zbrinjavanja i mogućih komplikacija bitno je za uspješnu perioperacijsku skrb, kao i za izbjegavanje pobola i smrtnosti

Stalni nadzor srčanog izbačaja metodama Picco i Lidco prema Pak-u u septičnih bolesnika: kalibrirati ili ne ?

The accuracy of cardiac output measurement by two most widely used methods of less invasive hemodynamic monitoring and by the standard technique of thermodilution with pulmonary catheter was assessed. The measurements were carried out in septic surgical patients immediately after and between system calibrations. Study results showed satisfactory compatibility of measurements performed by the two methods and by pulmonary catheter in both phases, thus system calibration being recommendable in hemodynamically unstable septic patients.U ovom radu uspoređivala se točnost mjerenja srčanog izbačaja pomoću dviju najčešće upotrebljavanih metoda manje invazivnog hemodinamskog nadzora i standardnom tehnikom termodilucije plućnim kateterom. Mjerenje je provedeno kod septičnih kirurških bolesnika u razdoblju neposredno nakon i između kalibracija sustava. Rezultati su pokazali zadovoljavajuću podudarnost mjerenja u obje faze primjenom obiju metoda i pomoću plućnog katetera, pa se kalibriranje sustava preporuča u hemodinamski nestabilnih septičnih bolesnika

Correction to: Redox Status and Antioxidative Cofactor Metals Influence Clinical and Pathological Characteristics of Papillary Thyroid Carcinoma and Colloid Goiter (Biological Trace Element Research, (2020), 197, 2, (349-359), 10.1007/s12011-019-01995-x)

Papillary thyroid carcinoma (PTC) is the endocrine neoplasm that occurs the most often worldwide, and its molecular pathophysiology is still not well characterized. Redox status is recognized as an important factor of carcinogenesis, but its influence on the PTC's clinical course needs to be better elucidated. The aim of this research was to determine the tissue redox status of 65 PTC and 45 colloid goiter (CG) patients together with antioxidative cofactor metal profiling. The malondialdehyde (MDA) concentration was used to access the prooxidation level, while antioxidant mechanisms were estimated by assaying the activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione reductase (GR). The antioxidative cofactor metals included quantification of Se, Cu, Zn, and Mn concentration. PTC tissues had normal prooxidation levels and increased GPx and GR activity. The activity of SOD has been significantly reduced in multicentric PTC dissemination and increased in smokers. SOD activity was directly dependent on MDA levels in CG tissues. CG patients with retrosternal goiter had reduced MDA concentration and SOD activity. Numerous correlations between redox parameters in PTC tissues reveal good co-activation of antioxidative mechanisms and cooperative response on prooxidation. PTC tissues had decreased Se levels and increased concentration of Cu and Mn in comparison to other tissues. MDA concentration and SOD activity were significant predictors of PTC's multicentric dissemination and for the existence of lymph node metastases, respectively. Particularly, the concentration of Cu predicted the retrosternal localization in CG patients. Significant findings presented in this study provide a possibility for development of novel prognostic molecular biomarkers of PTC and CG.The contribution corrects an equation from the paper: Rovcanin, B.; Stojsavljevic, A.; Kekic, D.; Gopcevic, K.; Manojlovic, D.; Jovanovic, M.; Knezevic, S.; Zivaljevic, V.; Diklic, A.; Paunovic, I. Redox Status and Antioxidative Cofactor Metals Influence Clinical and Pathological Characteristics of Papillary Thyroid Carcinoma and Colloid Goiter. Biol Trace Elem Res 2020, 197 (2), 349–359. [https://doi.org/10.1007/s12011-019-01995-x

Povećana stopa doniranja organa u kliničkoj bolnici sestara milosrdnica

The rate of organ donation reflects the level of the respective society and country development. In Croatia, attempts have been made to increase this rate. As a consequence, the number of potential donors with confirmed brain death was observed to have steadily increased during the 2004-2008 period. Data on all potential donors where the confirmation procedure for brain death was completed were retrieved and analyzed. The percentage of donors out of all persons diagnosed with brain death and all deaths recorded at the Central Intensive Care Unit and at all Hospital departments was calculated. The mean number or organs per donor was also calculated. During the 2004-2008 period, the number of donors per brain death persons was 5/unknown, 6/10, 8/13, 11/13 and 18120; mean age 51, 50, 39, 48 and 44; donor rate per Central Intensive Care Unit deaths 5.9010, 5.6%,5.8%, 10.4% and 12.1%; donor rate per all hospital deaths 0.4%, 0.5%, 0.5%, 1.5% and 1.9%; and number of organs per donor 1.6, 2.4, 2.6, 3.0 and2.7, respectively. Study results showed a steady increase in the number of donors and organs per donor at Sestre milosrdnice University Hospital during the 2004-2008 period. More intensive education should be organized at medical schools and for medical professionals to identify brain death persons and potential donors. In addition, mass media campaigns should improve public awareness and perception of the issue.Stopa donacije organa je mjerilo razvijenosti zemlje. Kako bi se ta razina povećala, u Hrvatskoj su poduzete određene mjere. Posljedično je zamijećen stalan porast potencijalnih donora u kojih je potvrđena moždana smrt. Prikazujemo stalan porast razine donora od 2004. do 2008. godine. Analizirani su podaci svih potencijalnih donora u kojih je proveden postupak potvrđivanja moždane smrti. Izračunat je postotak broja donora u odnosu na osobe u kojih je dijagnosticirana moždana smrt te u odnosu na sve umrle u Središnjoj jedinici intenzivnog liječenja i u cijeloj bolnici. Također je izračunat srednji broj doniranih organa po donoru. Od 2004. do 2008. godine broj donora na broj moždano mrtvih osoba je bio 5/ nepoznato, 6/10, 8/13, 11/13 i 18/20, dok je srednja dob bila 51, 50, 39, 48 i 44 godine. Od 2004. do 2008. godine broj donora na broj umrlih u Središnjoj jedinici za intenzivno liječenje je bio 5,9%, 5,6%, 5,8%, 10,4% i 12,1%, a na sve umrle u bolnici 0,4%,0,5%,0,5%,1,5% i 1,9%. Srednji broj organa po donoru od 2004. do 2008. je bio 1,6; 2,4; 2,6; 3,0; 2,7. Od 2004. do 2008. godine vidljiv je stalan porast broja donora i broja doniranih organa u Kliničkoj bolnici "Sestre milosrdnice" Potrebno je provesti izobrazbu na Medicinskom fakultetu i medu profesionalnim osobljem kako bi se prepoznale osobe s moždanom smrti i potencijalni donori. Također treba provesti kampanje u medijima kako bi se poboljšao stav javnosti u tom području

Konsenzus za dijagnosticiranje moždane smrti - smjernice za primjenu potvrdnih pretraga

Brain death is defined as the irreversible loss of all brain functions, including the brainstem. The diagnosis of brain death allows organ donation or withdrawal of support. Therefore the exact criteria for the diagnosis of brain death must be determined. In the Croatian Act on Transplantation, repeated neurologic examination must show loss of brainstem reflexes, and one confirmation test must be done. Several tests are available, showing the cessation of brain or brainstem activity, or confirming the cerebral circulatory arrest. Bedside evaluation is possible through electroencephysiologic and neurosonologic tests. Conventional or digital subtraction angiography is done in radiology suite, and isotope angiography and technetium-99m hexamethylpropyleneamine oxime (99Tc-HMPAO) at the Department of Nuclear Medicine. Such tests require special settings, therefore bedside test like electroencephalography, evoked potentials and neurosonology tests are preferred. All tests require trained personnel and strict protocols, which differ from routine investigations The confirmatory tests used in brain death confirmation, the techniques, criteria, results and validity of the tests are presented.Definicija moždane smrti obuhvaća gubitak svih funkcija mozga, uključujući moždanog stabla. Dijagnostika moždane smrti omogućava donaciju organa ili prekid potpore. Stoga se moraju točno odrediti kriteriji dijagnoze. Prema Hrvatskom zakonu o transplantaciji, ponovljeni neurološki pregled mora pokazati gubitak refleksa moždanog stabla a obavezan je i jedan od testova potvrde. Nekoliko je testova dostupno, koji pokazuju prestanak aktivnosti mozga ili moždanog stabla ili potvrđuju nastup moždanog prekida cirkulacije. Procjena uz krevet bolesnika je moguća upotrebom elektrofizioloških i neurosonoloških testova. Konvencionalna ili digitalna subtrakcijska angiografija se izvodi na radiologiji, a izotopna angiografija i perfuzija mozga heksametil-propilen-amin-oksimom (99mTc-HMPAO) u Klinici za nuklearnu medicinu. Takvi testovi zahtijevaju posebne pogodnosti, stoga se preferiraju testovi koji se primjenjuju uz krevet bolesnika kao elektroencefalografija, evocirani potencijali i neurosonološki testovi. Svi testovi zahtijevaju uvježbano osoblje i striktne protokole koji se razlikuju od onih koji se upotrebljavaju u rutinskoj dijagnostici. Prikazani su testovi koji se primjenjuju u potvrdi moždane smrti, tehnike, kriteriji, rezultati i vrijednosti testova

Korelacija između zbira Glasgowske ljestvice za komu i intrakranijskog tlaka u bolesnika s teškom ozljedom glave

Patients sustaining severe head injury require use of standardized treatment protocols, most of them focused on the maintenance of cerebral perfusion pressure. Among other goals, neurologic recovery can be expected if a satisfactory level of cerebral perfusion pressure has been achieved. The aim of the study was to assess the correlation between neurologic findings expressed as Glasgow Coma Scale (GCS) score, and intracranial cerebral perfusion and mean arterial pressure. Results obtained in 24 study patients pointed to negative correlation between GCS score and intracranial pressure (p=0.006), and positive correlation between GCS score and cerebral perfusion pressure (p=0.016). There was no statistically significant correlation between GCS score and mean arterial pressure, which could be explained by use of iatrogenic procedures for the maintenance of mean arterial pressure. In conclusion, the intracranial and cerebral perfusion pressures appear to correlate well with GCS score, thus monitoring of these pressures may be highly useful in the follow-up of patients with severe brain injury.U bolesnika s teškom ozljedom mozga neophodna je primjena standardiziranih protokola liječenja. Većina ih je usmjerena na održavanje cerebralnog perfuzijskog tlaka. Oporavak neurološkog statusa očekivan je ako se cerebralni perfuzijski tlako država u zadovoljavajućim granicama. Cilj ispitivanja bio je odrediti povezanost neurološkog statusa izraženog kao zbir Glasgowske ljestvice za komu (GCS) s intrakranijskim cerebralnim perfuzijskim i srednjim arterijskim tlakom. Podaci skupljeni tijekom liječenja 24 bolesnika s teškom ozljedom mozga ukazali su na postojanje negativne korelacije zbira GCS i intrakranijskog tlaka (p=0,006) te pozitivne korelacije zbira GCS i cerebralnog perfuzijskog tlaka (p=0,016). Nije bilo statistički značajne korelacije između zbira GCS i srednjeg arterijskog tlaka, što se može tumačiti jatrogenim postupcima održavanja srednjeg arterijskog tlaka. Zaključeno je da su praćeni intrakranijski i cerebralni perfuzijski tlakovi dobro povezani sa zbirom GCS. Promatranje ovih tlakova pouzdan je način praćenja bolesnika s teškom ozljedom mozga

Recombinant factor Vlla therapy in a patient on long term anticoagulant treatment with a bleeding and acute subdural hematoma

In this paper we report on the successful correction of a coagulopathy with activated recombinant factor seven (rFVIIa) therapy which enabled surgical removal of a life threatening subdural hematoma. The severe coagulopathy developed due to long term warfarin therapy, which followed heart valvular reconstruction and replacement. The coagulopathy failed to improve following fresh frozen plasma and vitamin K therapy. Activated recombinant factor VII therapy became the treatment of choice, which enabled the life saving surgical removal of the subdural hematoma