Effect of pretreatment with omega-3 polyunsaturated fatty acids (PUFAs) on hematological parameters and platelets aggregation in patients during elective coronary artery bypass grafting

Bacground/Aim. Using omega-3 polyunsaturated fatty acids (PUFAs) in coronary artery bypass graft surgery (CABG) could provide protection against ischemicreperfusion damage, prevention of postoperative arrhythmia and attenuation of inflammatory response. However, omega-3 PUFAs inhibit cyclooxygenase (and thus decrease the synthesis of thromboxane A2 from arachidonic acid in platelets), which leads to decreased platelet aggregation. In cardiac surgery it is necessary to achieve a balance between inhibition and full platelets function. It is as well as important to closely follow hematological parameters, impaired by CABG itself. Therefore, the aim of the study was to establish the effects of pretreatment with omega- PUFAs on hematological parameters and plateletes aggregation in patients with elective CABG. Methods. This prospective, randomized, placebo-controlled, single-center trial was performed on parallel groups. The patients (n = 40) undergoing elective CABG were randomized receiving preoperative intravenous omega-3 PUFAs (Omegaven® 10%) infusion (the PUFAs group) or the same volume of 0.9% saline solution infusion (the control group). Infusion was given a day before surgery and repeated four hours before starting extracorporeal circulation (CPB) via the peripheral vein at single doses of 100 mL (25 mL/h). Platelet function analysis was performed using multiple electrode aggregometry (MEA, multiplate-analyzer) before starting CPB and 2 h postoperatively for the patients of both groups. Results. There were no clinically relevant differences in baseline characteristics between the groups. Hematological parameters were not significantly different between the groups pre-, intra- and postoperatively. During the first 24 h after surgery, the loss of blood was similar in the PUFAs and the control group (680 ± 274 mL and 608 ± 210 mL, respectively; p = 0.356). Postoperatively, platelet aggregation was not significantly different between the PUFAs and the control group in adenosine diphosphate (ADP) test (39 ± 11 and 42 ± 15, respectively; p = 0.701), arachidonic acid (ASPI) test (64 ± 24 and 70 ± 27, respectively; p = 0.525) and trombin receptor-activating peptide (TRAP) test (68 ± 25 and 75 ± 26, respectively; p = 0.396), while their aggregation in collagen (COL) test was statistically significantly lower in the PUFAs related to the control group (32 ± 15 and 47 ± 20, respectively; p = 0.009). Conclusion. Acute pretreatment with omega-3 PUFAs insignificantly affected the activity of platelets and did not influence postoperative blood loss

Poređenje efikasnosti i bezbednosti preemptivnih protokola infuzije efedrina i fenilefrina – prevencija hipotenzije i uticaj na hemodinamske parametre tokom spinalne anestezije za carski rez

Introduction/Objective. Spinal anesthesia (SA) for cesarean section may lead to significant changes in hemodynamic parameters, especially hypotension. The aim of this study was to determine and compare the efficacy and safety of preemptive infusion protocols of the two most commonly used vasopressors, ephedrine (Group E, n = 29) and phenylephrine (Group P, n = 31) not only on prevention of hypotension but also to determine their effect on hemodynamic parameters, such as stroke volume (SV) and cardiac output (CO) using a continuous non-invasive hemodynamic monitor. Methods. The infusion of ephedrine was administered at the rate of 5 mg/min. immediately after SA. Phenylephrine was administered at an infusion rate of 25 ?g/min for two minutes prior to SA. Results. In Group E, mean systolic blood pressure (SBP) and heart rate (HR) were similar to baseline. CO was higher (

Откривање хипотензије током спиналне анестезије за царски рез континуираним неинвазивним праћењем артеријског притиска и интермитентним осцилометријским праћењем крвног притиска код болесница третираних ефедрином или фенилефрином

Introduction/Objective. Despite frequent side effects such as hypotension, spinal anesthesia (SA) is still one of the best anesthetic methods for elective cesarean section (CS). Intermittent, oscillometric, noninvasive blood pressure monitoring (NIBP) frequently leads to missed hypotensive episodes. The objective was to compare continuous non-invasive arterial pressure (CNAP) monitoring with NIBP in the terms of efficiency to detect hypotension. Methods. In this study, we compared CNAP and NIBP monitoring for hypotension detection in 76 patients divided into two groups of 38 patients treated with ephedrine (E) or phenylephrine (P), during threeminute intervals, starting from SA, by the end of the surgery. Results. In E group, significantly lower mean systolic blood pressure (SBP) values with CNAP compared with NIBP (p = 0.008) was detected. By monitoring CNAP, we detected 31 (81.6%) hypotensive patients in E group and significantly lower number, 20 (52.6%), with NIBP (p = 0.001), while in P group CNAP detected 34 patients (89.5%) and NIBP only 18 (47.3%), p = 0.001. By monitoring CNAP, we detected significantly higher number of hypotensive intervals in E and P groups (pУвод/Циљ Упркос честим нежељеним ефектима као што је хипотензија, спинална анестезија је и даље техника избора за планирани царски рез. Интермитентно неинвазивно праћење крвног притиска често не детектује хипотензивне епизоде. Циљ ове студије је био да се упореди континуирано неинвазивно праћење артеријског притиска са интермитентним неинвазивним праћењем крвног притиска у смислу ефикасности у откривању хипотензије.Методе Упоређивани су системи за континуирано неинвазивно праћење артеријског притиска и интермитентно неинвазивно праћење крвног притиска ради детекције хипотензије код 76 болесница подељених у две групе од по 38 болесница, третираних ефедрином (Е) или фенилефрином (Ф), на свака три минута, почевши од спиналне анестезије па све до краја операције.Резултати У групи Е су детектоване знатно ниже средње вредности систолног крвног притиска континуираним неинвазивним праћењем артеријског притиска у поређењу са интермитентним неинвазивним праћењем крвног притиска (p = 0,008). Континуираним неинвазивним праћењем артеријског притиска детектована је 31 (81,6%) хипотензивна болесница у групи Е и знатно мањи број, 20 (52,6%) болесница, интермитентним неинвазивним праћењем крвног притиска (p = 0,001), док је у групи Ф континуираним неинвазивним праћењем артеријског притиска детектована хипотензија код 34 болеснице (89,5%), а интермитентним неинвазивним праћењем крвног притиска код 18 (47,3%) болесница, p = 0,001. Континуираним неинвазивним праћењем артеријског притиска детектован је знатно већи број хипотензивних епизода у групама Е и Ф (p < 0,001). pH вредности умбиликалне крви биле су значајно ниже код хипотензивних у односу на нормотензивне болеснице у групама Е и Ф, и са континуираним неинвазивним праћењем артеријског притиска и интермитентним неинвазивним праћењем крвног притиска, респективно (p < 0,001, p = 0,027 у групи Е, и p = 0,009, p < 0,001 у групи Ф).Закључак Континуирано неинвазивно праћење артеријског притиска је много ефикасније у откривању хипотензије током царског реза у спиналној анестезији, што омогућава бржи третман и мање нежељених ефеката код мајке и новорођенчета

Surgical stress response following hip arthroplasty regarding choice of anesthesia and postoperative analgesia

Background/Aim. Significant surgical stress response consisting of hormonal, metabolic and inflammatory changes can be initiated by the hip replacement surgery. Appropriate choice of anesthesia and postoperative analgesia should provide diminution of surgical stress response and may reduce number of perioperative complications. Surgical stress response after peripheral nerve blocks has not been studied extensively in patients who underwent hip replacement. The aim of the study was to investigate whether continuous lumbar plexus block can significantly reduce surgical stress response in comparison to other types of postoperative analgesia – continuous epidural analgesia and intravenous patient controlled analgesia (PCA) with morphine. Methods. Prospective study included 60 patients, scheduled for total hip arthroplasty. The patients were randomized into 4 groups: group CNB (central nerve block - epidural), group PNB (Peripheral nerve block - lumbar plexus block), SAM (Spinal anesthesia- PCA (anesthesia) morphine) and GAM (General anesthesia + PCA with Morphine). Serum levels of cortisol, thyroid hormones (T3, T4) and thyroid stimulating hormone (TSH), insulin, glucose and C-reactive protein (CRP) were measured in all groups – preoperatively, as well as 4 h, 12 h and 24 h after surgery. Results. The study showed that average serum cortisol levels were significantly lower 4 h after the operation in the groups where methods of regional anesthesia were performed intraoperatively (SAM, CNB, PNB); (F = 19.867; p < 0.01). Groups with postoperative continuous catheter analgesia (CNB, PNB) had significantly lower serum cortisol levels 12 h after the operation (F = 8.050; p < 0.01). The highest serum insulin levels were detected 4 h postoperatively in the CNB and PNB group, while the lowest were in the GAM group (F = 5.811; p < 0.05). Twelve hours after the operation, the lowest values of insulin were measured in the SAM group (F = 5.052; p < 0.05), while 24 h postoperatively, the lowest values were found in the SAM and GAM group (F = 6.394; p < 0.05). T3, T4 and TSH levels showed slight reduction in comparison to preoperative values without statistical significance. Blood glucose levels were significantly different among the groups 4 h after surgery with the highest values recorded in the GAM group and the lowest ones in the SAM group (F = 10.084; p < 0.01). On the other hand, 12 h after the operation significant rise in blood glucose levels was detected in the SAM group (F = 7.186; p < 0.01) Levels of CRP increased remarkably 12 h and 24 h after the surgery, but without significant difference among the groups. Conclusion. Administration of postoperative analgesia using continuous lumbar plexus block following hip arthroplasty reduces significantly stress response in comparison to postoperative PCA with morphine and has comparable effects on hormone release to epidural analgesia. Spinal anesthesia provides the best diminution of surgical stress response in the early postoperative period in comparison with other types of intraoperative analgesia

VALIDITY OF CORE NEEDLE BIOPSY IN THE HISTOPATHOLOGICAL VERIFICATION OF PAROTID GLAND LESIONS

Background and purpose: An adequate diagnosis of a parotid gland enlargement is crucial for an appropriate treatment. The aim of the study was to evaluate effectiveness and minimal invasiveness of diagnostic procedures of core-needle biopsy. Materials and Methods: This study involved 67 patients, aged 40 to 90 years, with a tumor mass in the submandibular and parotid region. Method used for taking samples of pathological masses was BD Disposable guillotine spring-loaded needle for biopsies on soft tissues. Final diagnoses were established on the basis of surgical-pathological results in 67 cases, and on the basis of histopathological analysis of core-biopsy samples. Results: Compared with results of surgical biopsy, core-needle biopsy had sensitivity of 100% in differentiating benign from malignant lesions and in setting up an adequate diagnosis. Its positive predictive values were 100% in diagnosing malignancy. There were found 28 non-malignant and 39 malignant lesions with fewer disadvantages for patients

New aspects of sepsis pathophysiology in critically ill

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Efficacy of external warming in attenuation of hypothermia in surgical patients

Background/Aim. Hypothermia in surgical patients can be the consequence of long duration of surgical intervention, general anaesthesia and low temperature in operating room. Postoperative hypothermia contributes to a number of postoperative complications such as arrhythmia, myocardial ischemia, hypertension, bleeding, wound infection, coagulopathy, and prolonged effect of muscle relaxants. External heating procedures are used to prevent this condition. The aim of this study was to evaluate the efficiency of external warming system in alleviation of cold stress and hypothermia in patients who underwent major surgical procedures. Methods. The study was conducted in the Military Medical Academy in Belgrade. A total of 30 patients of both genders underwent abdominal surgical procedures, randomly divided into two equal groups: the one was externally warmed using warm air mattress (W), while in the control group (C) surgical procedure was performed in regular conditions, without additional warming. Oesophageal temperature (Te) was used as indicator of changes in core temperature, during surgery and awakening postoperative period, and temperature of control sites on the right hand (Th) and the right foot (Tf) reflected the changes in skin temperatures during surgery. Te and skin temperatures were monitored during the intraoperative period, with continuous measurement of Te during the following 90 minutes of the postoperative period. Heart rates and blood pressures were monitored continuously during the intraoperative and awakening period. Results. In the W group, the average Te, Tf and Th did not change significantly during the intraoperative as well as the postoperative period. In the controls, the average Te significantly decreased during the intraoperative period (from 35.61 ± 0.35ºC at 0 minute to 33.86 ± 0.51ºC at 120th minute). Compared to the W group, Te in the C group was significantly lower in all the observed periods. Average values of Tf and Th significantly decreased in the C group (from 30.83 ± 1.85 at 20th minute to 29.0 ± 1.39ºC at 120th minute, and from 32.75 ± 0.96 to 31.05 ± 1.09ºC, respectively). Conclusion. The obtained results confirm that the external warming using warm air mattress was able to attenuate hypothermia, i.e. substantial decrease in core temperature, compared with the similar exposure to cold stress in the control group

Quality of life of the mechanically ventilated patients with community-acquired pneumonia

Background/Aim. Patients with pneumonia who require mechanical ventilation (MV) are associated with several poor outcomes such as prolonged hospitalization, higher rate of mortality and increased spread of antibioticsresistant pathogens. MV in patients with communityacquired pneumonia (CAP) could cause development of psychological symptoms, often neglected in the Intensive Care Units (ICU) as well as decreased quality of life after the withdrawal of the MV. The aim of the study was to evaluate the quality of life in patients with CAPs treated with MV in ICU. Methods. The study was designed as a cohort study of hospital-treated patients with CAP with prospective data collection. The quality of life was defined as the primary outcome, while the use of MV was assumed as the primary prognostic factor that adversely affected the outcome. The patients were recruited from the population of patients with CAPs who were hospitalized at the ICU, Clinical Center Kragujevac, Serbia, from January 2013 to January 2014. The experimental group consisted of patients who were on MV while the control group included patients who were treated for CPAs in the ICU, but were not subjected to MV. The quality of life was assessed by using patient-rated Euro Quality of Life (EuroQoL) Group-EQ-5D index. The calculation of the total EQ-5D-5L score values was performed by using the predefined, validated mapping key according to response combinations. Statistical analysis was performed by using χ2 test, Student's t-test, univariate and multivariate logistic regression analyses. Results. The patients with MV had worse EQ5D-5L values in comparison to the control group for all 5 domains. Mobility, self-care and usual activities were negatively affected during the whole follow-up period. Pain or discomfort and anxiety or depression differed significantly between the study group and the control group at days 7 and 30. Conclusion. Patients with MV tend to have poorer quality of life, especially in 3 domains. The main reasons are the presence of chronic comorbidities in the population that require MV. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. 175007

Malignant fibrous histiocytoma of the right upper leg: A case report

Introduction. Malignant fibrous histiocytoma is a fast spreading pleomorphic sarcoma with a high malignant potential. Its spreading is characterized with local invasion and distant metastazes with early onset. Most common localisations of development are extremities, trunk and retroperitoneum. Given the line of rare case and specimen, lack of a clear etiology and mechanisms of this disease, as well as adequate histopathologic findings and intraoperative documentation, we presented current status, discuss putative etiology, histopathology with variant morphology, differential diagnosis and treatment modalities. Case report. We presented a 56-years-old female Serbian with tumor in the thigh that clinically resembles incapsulated hematoma. Computed tomography revealed intramuscular tumor with a heterodense structure and compression on surround tissue. Ex tempore biopsy specimen showed malignant potential of the tumor. Wide and radical excision of the nodule has been done, and definitive histopathological verification revealed malignant fibrous histiocytoma. Conclusion. Malignant fibrous histiocytoma is a most common type of soft tissue sarcomas in adults. Frequent localization is on lower extremities, and every rapidly enlarging nodule in this localization that on computed tomography is like incapsulated hematoma with necrotic zone should alert suspicion on presence of this type of sarcoma. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. III41007 and Grant no. III41010