Primjena veno-venske izvantjelesne membranske oksigenacije kod pacijenata s limfomom i teškim akutnim respiratornim distresnim sindromom: serija slučajeva

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.Cilj: Prikazati klinički tijek dvoje pacijenata, pacijenta s Hodgkinovim limfomom i pacijentice s ne-Hodgkinovim limfomom, koji su razvili teški refraktorni akutni respiratoracijski distresni sindrom (engl. acute respiratory distress syndrome; ARDS) te su liječeni veno-venskom izvantjelesnom membranskom oksigenacijom (engl. veno-venous extracorporeal membrane oxygenation; VV ECMO). Prikaz slučaja: Nakon kemoterapije pacijenti su razvili febrilnu neutropeniju, pneumoniju i ARDS, nakon čega su premješteni u jedinicu intenzivnog liječenja. Unatoč orotrahealnoj intubaciji i protektivnoj mehaničkoj ventilacijskoj potpori, došlo je do pogoršanja njihova respiracijskog statusa te se odlučilo uvesti VV ECMO potporu. Imali su kompliciran klinički tijek praćen teškim komplikacijama povezanim s korištenjem ECMO-a. Kod pacijenta s Hodgkinovim limfomom razvile su se sljedeće komplikacije: kardijalni arest; laceracija aurikule desnog atrija s tamponadom perikarda, što je zahtijevalo kirurško liječenje; ishemija desne noge koja je zahtijevala transfemoralnu amputaciju; tromboza membranskog oksigenatora; nekoliko septičkih epizoda praćenih teškom hemodinamskom nestabilnošću te desnostrani tenzijski pneumotoraks. Iako se uspješno odvaja od ECMO-a, pacijent je preminuo na odjelu zbog sepse s multiorganskim zatajenjem. U pacijentice s ne-Hodgkinovim limfomom razvilo se difuzno orofaringealno i kontinuirano obostrano plućno krvarenje; sekundarna bakterijska pneumonija; opsežan pneumomedijastinum i subkutani emfizem. Unatoč svim mjerama potpore, pacijentica je preminula tokom liječenja ECMO-om zbog dekompenzacije respiracijskog zatajivanja. Zaključak: Pacijenti s hematološkim neoplazmama liječeni ECMO-om imaju loše terapijske ishode praćene čestim i teškim komplikacijama. Potrebna su klinička istraživanja s posebnom pažnjom na izbor pacijenata, prevenciju, dijagnozu i liječenje komplikacija povezanih s korištenjem ECMO-a

Application of veno-venous extracorporeal membrane oxygenation in pediatric patient with severe brain injury: case report

Cilj: Veno-venska izvantjelesna membranska oksigenacija (engl. veno-venous extracorporeal membrane oxygenation; VV ECMO) metoda je pružanja potpore funkciji pluća u pacijenata s teškim reverzibilnim zatajenjem respiracije. Prikazan je slučaj politraumatizirane pedijatrijske pacijentice s teškom ozljedom mozga s ciljem utvrđivanja može li se takve pacijente liječiti ovom metodom. Prikaz slučaja: U Jedinicu intenzivnog liječenja (JIL) zaprimljena je osmogodišnja pacijentica nastradala kao pješakinja u automobilskoj nesreći. Premještaj je bio dogovoren zbog nestabilnog stanja vitalnih funkcija tijekom operativnog zahvata u drugoj ustanovi. Pregledom su utvrđeni višestruki prijelomi viscerokranija, teška ozljeda mozga (subarahnoidalno krvarenje) i kontuzija pluća s razvojem akutnog respiratornog distres sindroma. Pacijentica je bila umjetno ventilirana i pri prijemu je izmjerena saturacija krvi kisikom 55 %. Pristupilo se postavljanju VV ECMO-a preko periferne kanulacije, na što se saturacija u arterijskoj krvi popravila. Kontrolirani su respiracijski parametri uredni uz VV ECMO, a nalazi slikovnih tehnika pokazali su potpunu resorpciju subarahnoidalnog krvarenja i hemoragičnih žarišta na mozgu, kao i puno bolju prozračnost obaju plućna krila. Tijekom sedmog dana pristupilo se odvajanju od VV ECMO-a, uz daljnju ventilacijsku potporu. Desetoga dana liječenja pacijentica se premjestila na pedijatrijski JIL. Zaključci: Unatoč raspravama i potencijalnim rizicima postavljanja VV ECMO-a, ovaj primjer potvrđuje kako teška ozljeda mozga ne predstavlja apsolutnu kontraindikaciju za primjenu VV-ECMO-a. Kao i kod drugih medicinskih intervencija, i ova metoda nosi rizike, zbog čega se mora utvrditi stvarna potreba za svakog pacijenta individualno. Nove mogućnosti otvaraju i sustavi koji ne zahtijevaju sistemsku primjenu antikoagulacije.Aim: Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used to support lung function in patients with severe respiratory failure. A case is presented of a pediatric polytraumatized patient with severe brain injury to determine whether such patients can be treated with this method. Case Report: An eight-year-old patient was admitted in Intensive Care Unit (ICU) after being injured in a car accident. Transfer from another institution was agreed upon due to an unstable condition of vital functions during an operation. Multiple viscerocranial fractures, severe brain injury (subarachnoid haemorrhage and contusions) and acute respiratory distress syndrome were determined by examination. Patient was artificially ventilated and at admission, had extremely low oxygen saturation of 55%. The VV ECMO was set up by peripheral cannulation, after which saturation in arterial blood significantly improved. The respiratory parameters were controlled with VV ECMO . Findings with imaging techniques showed complete resorption of subarachnoidal bleeding and haemorrhagic focal points on the brain and better lung transparency. During the seventh day, VV ECMO was removed, with further ventilation support. On the tenth day of treatment, the patient was transferred to pediatric ICU. Conclusions: Despite numerous debates and potential risks, this case shows that severe brain damage is not an absolute contraindication for the application of VV ECMO. Since it carries certain risks, it is necessary to determine the actual need for each patient individually. New systems that do not require systemic application of anticoagulation present another possibility in treating these patients

Course of events and cardiopulmonary resuscitation outcomes in Clinical Hospital Centre Rijeka

Cilj: Ishod srčanog zastoja i mjera kardiopulmonalne reanimacije ovisi o implementaciji smjernica ERC-a, kao i njihovom pravovremenom provođenju. Cilj istraživanja bio je utvrditi razlike u provođenju mjera kardiopulmonalne reanimacije unutar pojedinih odjela Kliničkog bolničkog centra (KBC) Rijeka. Ispitanici i metode: Prospektivnom studijom obuhvaćena su 63 bolesnika liječena u KBC-u Rijeka kojima je utvrđen srčani zastoj i nad kojima su provedene mjere kardiopulmonalne reanimacije u razdoblju od 1. lipnja 2011. godine do 1. rujna 2012. godine. Rezultati: U 23 bolesnika (36 %) došlo je do povratka spontane cirkulacije, dok je u 40 bolesnika (64 %) ishod bio letalan. Mjere osnovnog održavanja života (BLS, engl. basic life support) do dolaska tima za reanimaciju poduzete su u svih 63 bolesnika (100 %). U 79 % bolesnika prvi ritam zabilježen na monitoru bio je ritam koji se ne defibrilira (asistolija ili električna aktivnost bez pulsa), dok je u ostalih bolesnika (21 %) početni ritam bio ritam koji se defibrilira (ventrikularna tahikardija bez pulsa ili ventrikularna fibrilacija). U navedenih bolesnika u kojih je došlo do povratka spontane cirkulacije, 6 bolesnika (26 %) imalo je pozitivan neurološki ishod (CPC-vrijednost 1 i 2) dok je 17 bolesnika (74 %) imalo značajna neurološka oštećenja (CPC-vrijednost 3, 4 i 5). Rasprava i zaključak: Kako bi reanimacije imale što bolji ishod neophodno je provoditi edukaciju medicinskog osoblja o mjerama osnovnog i naprednog održavanja života u Jedinicama intenzivnog liječenja i Centrima za hitnu medicinu, kao i na ostalim bolničkim odjelima. Potrebno je uspostaviti tim za reanimaciju i sustav jedinstvenog obavještavanja o vitalno ugroženom bolesniku te standardizirati opremu i materijal na odjelima i mjestima visokog rizika za nastup srčanog zastoja.Objective: The outcome of cardiac arrest and cardiopulmonary resuscitation measures depends on the implementation of the ERC guidelines as well as their timely enforcement. The aim of the study was to determine differences in measures of cardiopulmonary resuscitation (CPR) provided within different departments of Clinical Hospital Centre (KBC) Rijeka. Patients and methods: Prospective analysis covered 63 patients who underwent CPR following cardiac arrest in KBC Rijeka during 15-month study period (June 2011 to September 2012). Results: Return of spontaneous circulation was achieved in 23 patients (36 %), whereas 40 patients (64 %) had lethal outcome. Until the arrival of resuscitation team basic life support (BLS) was provided to all patients (100 %). In most cases (79 %) initial rhythm was non-shockable rhythm (asystole or pulseless electrical activity), while the rest (21 %) were shockable rhythms (pulseless ventricular tachycardia or ventricular fibrilation). After the return of spontaneous circulation 6 patients (26 %) had favorable neurological outcome (CPC-score 1 and 2) while 17 patients (74 %) had significant neurological disorder (CPC-score 3,4 and 5). Discussion and conclusion: In order to improve the outcome it is necessary to provide education in basic and advanced life support for all medical personnel on hospital wards as well as Intensive care units and Emergency medicine department. Rapid response team and the use of ‘track-and-trigger systems’ to detect the deteriorating patient should be organized together with equipment and material normative standards at wards and departments with high risk of cardiac arrest occurrence

Course of events and cardiopulmonary resuscitation outcomes in Clinical Hospital Centre Rijeka

Cilj: Ishod srčanog zastoja i mjera kardiopulmonalne reanimacije ovisi o implementaciji smjernica ERC-a, kao i njihovom pravovremenom provođenju. Cilj istraživanja bio je utvrditi razlike u provođenju mjera kardiopulmonalne reanimacije unutar pojedinih odjela Kliničkog bolničkog centra (KBC) Rijeka. Ispitanici i metode: Prospektivnom studijom obuhvaćena su 63 bolesnika liječena u KBC-u Rijeka kojima je utvrđen srčani zastoj i nad kojima su provedene mjere kardiopulmonalne reanimacije u razdoblju od 1. lipnja 2011. godine do 1. rujna 2012. godine. Rezultati: U 23 bolesnika (36 %) došlo je do povratka spontane cirkulacije, dok je u 40 bolesnika (64 %) ishod bio letalan. Mjere osnovnog održavanja života (BLS, engl. basic life support) do dolaska tima za reanimaciju poduzete su u svih 63 bolesnika (100 %). U 79 % bolesnika prvi ritam zabilježen na monitoru bio je ritam koji se ne defibrilira (asistolija ili električna aktivnost bez pulsa), dok je u ostalih bolesnika (21 %) početni ritam bio ritam koji se defibrilira (ventrikularna tahikardija bez pulsa ili ventrikularna fibrilacija). U navedenih bolesnika u kojih je došlo do povratka spontane cirkulacije, 6 bolesnika (26 %) imalo je pozitivan neurološki ishod (CPC-vrijednost 1 i 2) dok je 17 bolesnika (74 %) imalo značajna neurološka oštećenja (CPC-vrijednost 3, 4 i 5). Rasprava i zaključak: Kako bi reanimacije imale što bolji ishod neophodno je provoditi edukaciju medicinskog osoblja o mjerama osnovnog i naprednog održavanja života u Jedinicama intenzivnog liječenja i Centrima za hitnu medicinu, kao i na ostalim bolničkim odjelima. Potrebno je uspostaviti tim za reanimaciju i sustav jedinstvenog obavještavanja o vitalno ugroženom bolesniku te standardizirati opremu i materijal na odjelima i mjestima visokog rizika za nastup srčanog zastoja.Objective: The outcome of cardiac arrest and cardiopulmonary resuscitation measures depends on the implementation of the ERC guidelines as well as their timely enforcement. The aim of the study was to determine differences in measures of cardiopulmonary resuscitation (CPR) provided within different departments of Clinical Hospital Centre (KBC) Rijeka. Patients and methods: Prospective analysis covered 63 patients who underwent CPR following cardiac arrest in KBC Rijeka during 15-month study period (June 2011 to September 2012). Results: Return of spontaneous circulation was achieved in 23 patients (36 %), whereas 40 patients (64 %) had lethal outcome. Until the arrival of resuscitation team basic life support (BLS) was provided to all patients (100 %). In most cases (79 %) initial rhythm was non-shockable rhythm (asystole or pulseless electrical activity), while the rest (21 %) were shockable rhythms (pulseless ventricular tachycardia or ventricular fibrilation). After the return of spontaneous circulation 6 patients (26 %) had favorable neurological outcome (CPC-score 1 and 2) while 17 patients (74 %) had significant neurological disorder (CPC-score 3,4 and 5). Discussion and conclusion: In order to improve the outcome it is necessary to provide education in basic and advanced life support for all medical personnel on hospital wards as well as Intensive care units and Emergency medicine department. Rapid response team and the use of ‘track-and-trigger systems’ to detect the deteriorating patient should be organized together with equipment and material normative standards at wards and departments with high risk of cardiac arrest occurrence

A 23-year-old man with left lung atelectasis treated with a targeted segmental recruitment maneuver: a case report

BACKGROUND: Lung atelectasis are nonventilated parts of lung tissue and occur as a result of the collapse of the pulmonary parenchyma (alveoli). Various therapeutic procedures for inflating the collapsed pulmonary parenchyma, such as bronchial aspiration and/or standard recruitment maneuvers, are not always successful. CASE PRESENTATION: We report a case of a 23-year-old Croatian man with a parapharyngeal abscess on the left side of the neck with spreading of infection in the mediastinum and left side of the thorax and consequent major atelectasis of the left lung. The patient was mechanically ventilated. We decided to apply a new method in which a pulmonary artery catheter was placed (guided by bronchoscope) on the entrance to the lower left bronchus. The pulmonary artery catheter balloon was inflated to achieve bronchial closure. Using another respirator, we ventilated the affected lobe separately with continuously high pressure of 30 cmH2O. After 30minutes, we removed the pulmonary artery catheter from the lower left bronchus and placed it in the upper left bronchus and repeated the procedure. Our method allowed a significantly longer duration (30minutes) of continuously high pressure of 30 cmH2O separately to only one of the total of five lobes of the lungs while the other four lobes were simultaneously ventilated continuously with protective ventilation mode. CONCLUSION: Use of a pulmonary artery catheter and two respirators in our patient's case proved to be a successful method for recruiting the atelectatic lung while maintaining protective ventilation of the lung segments without atelectasis

Specificities of anesthesia management for kidney transplantation

Transplantacija bubrega predstavlja najbolju metodu liječenja terminalne faze kronične bubrežne bolesti. Pripremu pacijenata za zahvat vodi tim u koji su uključeni nefrolog, kirurg – urolog, anesteziolog te liječnik obiteljske medicine, čija je međusobna suradnja nezaobilazni dio skrbi o pacijentu. U prijeoperacijskoj pripremi anesteziolog se susreće s brojnim komorbiditetima, kompleksnom anamnezom te širokim spektrom pacijentove medikamentozne terapije uz naglasak na kardiovaskularne bolesti koje predstavljaju najčešći uzrok smrtnosti u ovoj skupini pacijenata. Pojavnost hematoloških, metaboličkih, respiratornih i endokrinih bolesti česta je, te je iznimno važna optimalizacija pacijentova općeg stanja prije operacijskog zahvata. Transplantacija bubrega je zahvat koji se obično ne može planirati i prema njemu se treba ponašati kao prema hitnom zahvatu, čime se povećava rizik razvoja komplikacija. Za vrijeme samog zahvata koji se izvodi u općoj, balansiranoj anesteziji, uloga anesteziologa je poznavanje farmakokinetike i farmakodinamike lijekova te vođenje anestezije koja će omogućiti urednu funkciju perfuzije presatka, što se postiže održavanjem adekvatnih vrijednosti krvnog tlaka. Važno je pravovremeno započinjanje antibiotske i imunosupresivne terapije uz zadovoljavajuću analgeziju. U daljnjem poslijeoperacijskom tijeku nužno je rano prepoznavanje i prevencija mogućih komplikacija kako bi se spriječilo neželjeno odbacivanje bubrežnog presatka.Kidney transplantation represents the best method for treating end-stage renal disease. The procedure is led by a team involving a nephrologist, a urologist, an anesthesiologist and a family medicine doctor whose cooperation is an indispensable part of patient care. The anesthesiologist encounters numerous patient’s comorbidities with a complex medical history and a wide range of medications. The emphasis is set on cardiovascular diseases which are the most common cause of mortality in this group of patients. The incidence of hematological, metabolic, respiratory and endocrine diseases is common, and it is extremely important to optimize the patient’s general condition prior to surgery. Kidney transplantation usually cannot be planned so it should be treated as an emergency, increasing the risk of complications. During the procedure that is performed under general, balanced anaesthesia, the role of the anesthesiologist is to know pharmacokinetics and pharmacodynamics of the drugs. Maintenance of blood pressure during anesthesia ensures an adequate kidney transplant perfusion. Early antibiotic and immunosuppressive therapy with satisfactory analgesia is important. In the postoperative course, early identification and prevention of possible complications is necessary to prevent unwanted kidney transplant rejection

The surgical progress of kidney transplantation programme in Rijeka

Riječki transplantacijski program započeo je eksperimentalnom kirurgijom i organizacijom centra za dijalizu na Odjelu za urologiju Klinike za kirurgiju na Sušaku. Uz pomoć vlastitog iskustva i boravkom u vanjskim centrima izvrsnosti ostvareni su uvjeti za početak rada s kandidatima za transplantaciju bubrega. Tako je 30. siječnja 1971. godine u našem centru učinjena prva uspješna transplantacija bubrega u Hrvatskoj i tadašnjoj Jugoslaviji. Slijedile su godine u kojima je transplantacija bubrega postala rutinski operacijski zahvat, ali zahvat koji je uvijek zahtijevao angažman multidisciplinarnog tima. Tijekom pet desetljeća predanog rada s kirurške strane su uvedena brojna unaprjeđenja transplantacijskoga programa, od kojih su mnoga po prvi put učinjena u Hrvatskoj i u zemljama u okruženju. To su, primjerice, ortotopne transplantacije bubrega, en-bloc transplantacija bubrega, transplantacija uz korištenje urinarne derivacije i supstitucije vijugom tankog crijeva, dvostruka transplantacija bubrega te transplantacija potkovičastog bubrega. U ovom preglednom radu prikazat ćemo kirurške posebnosti našega transplantacijskog programa.Kidney transplantation programme in Rijeka started with experimental surgery. The experience from this field combined with education in foreign centers of excellence was a prerequisite for starting this programme on the patients. The first kidney transplantation in our center was performed on January 30th 1971. This was also the first kidney transplantation in Croatia and former Yugoslavia. In the following years the kidney transplantation became a routine surgical procedure but always using multidisciplinary approach. During years and decades of dedicated surgical work many surgical improvements were achieved and many of them were performed in our center for the first time in Croatia and surrounding countries. Some of them are: orthotopic kidney transplantation, en-bloc kidney transplantation, transplantation using urinary diversion and transplantation of horseshoe kidney. In this review article we will present surgical achievements of our transplant team

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

Background: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. Methods: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. Results: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. Conclusions: Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs

Epidemiology, Practice of Ventilation and Outcome for Patients at Increased risk of Postoperative Pulmonary Complications: Las Vegas - an Observational Study in 29 Countries

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome