Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

As solid organ transplantation increases and patient survival improves, it will become more common for these patients to present for nontransplant surgery. Recipients may present with medical problems unique to the transplant, and important considerations are necessary to keep the transplanted organ functioning. A comprehensive preoperative examination with specific focus on graft functioning is required. The anesthesiologist needs to pay close attention to considerations of immunosuppressive regimens, blood product administration, drug interactions as well as the risk and benefits of invasive monitoring in these immunosuppressed patients. This article reviews the post-transplant physiology and anesthetic considerations for patients after solid organ transplantation

Upala pluća uzrokovana ventilatorom: usporedba bolesnika s kadaveričnim presatkom jetre i kirurških bolesnika bez presatka

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes.Upala pluća uzrokovana ventilatorom česta je komplikacija u jedinicama intenzivnog liječenja kirurških bolesnika, naročito onih s visokim stupnjem disfunkcije organa kod prijma. Ispitivala se učestalost i klinički ishod upale pluća uzrokovane ventilatorom kod bolesnika podvrgnutih velikim abdominalnim operativnim zahvatima te kod bolesnika nakon kadaverične transplantacije jetre. U studiju su bili uključeni bolesnici koji su u Jedinici intenzivnog liječenja boravili duže od četiri dana, koji su prošli operaciju ili transplantaciju te koji su bili mehanički ventilirani duže od 48 sati. Dijagnoza se temeljila na kombinaciji radioloških znakova (progresija infiltrata na snimkama prsišta), kliničkih znakova (vrućica >38,3 °C, leukociti >12×109/mL) te mikrobioloških podataka (pozitivna kultura aspirata traheje >105 i/ili bronhoalveolarnog lavata >104 kolonije/mL). Pregledani su medicinski zapisi 1037 bolesnika od kojih je njih 157 bilo mehanički ventilirano duže od 48 sati: 62 transplantiranih i 95 netransplantiranih. Samo 39 (24,84%) bolesnika zadovoljilo je kriterije. Nije nađena razlika u spolu, dobi, trajanju mehaničke ventilacije, duljini boravka ili ishodu između ispitivanih skupina. Međutim, glavnu razliku činio je bodovni sustav disfunkcije organa kod prijma (Simplifi ed Acute Physiology Score II), koji je bio veći kod netransplantiranih bolesnika (42±16 prema 31±9; p=0,03). Multirezistentne gram-negativne bakterije bile su vodeći uzročnik (82,03%). U jedinicama intenzivnog liječenja kirurških bolesnika transplantacija jetre sama po sebi ne povećava rizik za nastanak upale pluća uzrokovane ventilatorom kao ni lošiji ishod tih bolesnika

Physiology and Pharmacology of Epidurally Administered Drugs

In the last few decades, epidural administration of various drugs has gained popularity and widespread clinical acceptance. Epidural administration of local anesthetics and opioids has been considered “state of the art” in acute pain management (thoracic and major abdominal surgery, labor). Its advantage is that it yields profound, long-lasting, dose-dependent analgesia, leaving other sensory and motor functions intact. It facilitates early patient mobilization and ambulation and therefore reduces the risk of postoperative thromboembolism and respiratory complications. The increment in the elderly population caused an increase in musculoskeletal and spine diseases and thus, epidural steroid injections have become highly effective for chronic pain treatment. There are many factors that have an impact on drug physiology and pharmacology in the epidural space and, therefore, can modify epidural anesthesia or the expected effect of another medication. This chapter provides insight into this complex and comprehensive topic to demonstrate a predictable pattern that can provide a safe and accurate guide to clinical practice

RETROSPEKTIVNA STUDIJA INCIDENCIJE I POSLIJEOPERACIJSKIH KOMPLIKACIJA AKUTNOG BUBREŽNOG OŠTEĆENJA NAKON KARDIJALNIH ZAHVATA

Introduction: Cardiac surgery associated acute kidney injury (CSA-AKI) is an important complication. It is recognized as the second cause of AKI in the intensive care patients after sepsis. Methods: We conducted a single center retrospective threeyear cohort study to reveal the incidence of the postoperative AKI genesis and severity, as well as the use of continuous renal replacement therapy in patients with normal preoperative renal function submitted to cardiac surgery. Our study included 1000 patients. Secondary outcomes were length of intensive care and hospital stay, major postoperative complications, and in-hospital mortality rate. Statistical analysis was applied to correlate CSA-AKI development and patient perioperative variables. Results: The overall CSA-AKI incidence was 15.1% (n=151). The incidence of CSA-AKI was 12.8% (n=128) in stage 1; 1.9% (n=19) in stage 2; and 0.4% (n=4) in stage 3 according to the KDIGO AKI (RIFLE/AKIN) criteria. The incidence of continuous renal replacement therapy in the AKI group was 2.65% or 0.4% of the total cohort (n=4). The CSA-AKI inhospital mortality rate was 2.65% (n=4), while AKI patients that required dialysis survived. Conclusion: Once again, our study revealed the importance of timely recognizing CSA-AKI. It also reaffi rmed CSA-AKI as a serious complication with a high incidence rate. We also confi rmed the usefulness of preoperative AKI risk prediction models such as Cleveland Clinic Score in everyday clinical practice.Uvod: Akutno bubrežno oštećenje (ABO) je ozbiljna komplikacija kardijalne kirurgije. Istraživanja su pokazala da je kardijalna kirurgija po učestalosti drugi uzrok ABO u jedinicama intenzivnog liječenja. Metode: Provedeno je retrospektivno istraživanje za razdoblje od tri godine kako bi se utvrdila incidencija ABO, odredio stupanj ozbiljnosti ABO te incidencija kontinuirane bubrežne nadomjesne terapije u bolesnika s urednom prijeoperacijskom bubrežnom funkcijom podvrgnutih kardijalnom zahvatu. U istraživanje je bilo uključeno 1000 ispitanika. Ovim istraživanjem htjeli smo potvrditi povezanost između prijeoperacijskih čimbenika rizika iz prediktivnog modela Cleveland Clinic Score i intraoperacijskih rizičnih varijabla kardijalne kirugije i anestezije s nastankom poslijeoperacijskog ABO. Sekundarni ishod je pokazao incidenciju velikih poslijeoperacijskh komplikacija u bolesnika s ABO povezanim s kardijalnim zahvatom. Rezultati: Ukupna incidencija ABO bila je 15,1 % (n=151). Učestalost ispitanika sa stadijem 1 ABO bila je 12,8 % (n=128), sa stadijem 2 1,9 % (n=19) te sa stadijem 3 0,4 % (n=4) klasifi ciranima prema kriteriju KDIGO AKI (RIFLE/AKIN). Učestalost primjene kontinuirane bubrežne nadomjesne terapije u ispitanika s ABO iznosila je 2,65 %, odnosno 0,4 % cijele kohorte ispitanika (n=4). Bolnička stopa smrtnosti bolesnika s ABO bila je 2,65% (n=4). Zanimljivo je da su svi bolesnici podvrgnuti kontinuiranoj bubrežnoj nadomjesnoj terapiji zbog ABO preživjeli. Zaključak: Ovim smo istraživanjem još jednom potvrdili važnost pravodobnog prepoznavanja poslijeoperacijskog ABO kao ozbiljne komplikacije kardijalnih zahvata. Potvrdili smo da uporaba prijeoperacijskh prediktivnih modela rizika za nastanak ABO nakon kardijalnih zahvata olakšava prepoznavanje rizičnih bolesnika i pravodobnu primjenu mjera prevencije i liječenja ABO. Najpoznatiji prediktivni model je Cleveland Clinic Score

RETROSPEKTIVNA STUDIJA INCIDENCIJE I POSLIJEOPERACIJSKIH KOMPLIKACIJA AKUTNOG BUBREŽNOG OŠTEĆENJA NAKON KARDIJALNIH ZAHVATA

Introduction: Cardiac surgery associated acute kidney injury (CSA-AKI) is an important complication. It is recognized as the second cause of AKI in the intensive care patients after sepsis. Methods: We conducted a single center retrospective threeyear cohort study to reveal the incidence of the postoperative AKI genesis and severity, as well as the use of continuous renal replacement therapy in patients with normal preoperative renal function submitted to cardiac surgery. Our study included 1000 patients. Secondary outcomes were length of intensive care and hospital stay, major postoperative complications, and in-hospital mortality rate. Statistical analysis was applied to correlate CSA-AKI development and patient perioperative variables. Results: The overall CSA-AKI incidence was 15.1% (n=151). The incidence of CSA-AKI was 12.8% (n=128) in stage 1; 1.9% (n=19) in stage 2; and 0.4% (n=4) in stage 3 according to the KDIGO AKI (RIFLE/AKIN) criteria. The incidence of continuous renal replacement therapy in the AKI group was 2.65% or 0.4% of the total cohort (n=4). The CSA-AKI inhospital mortality rate was 2.65% (n=4), while AKI patients that required dialysis survived. Conclusion: Once again, our study revealed the importance of timely recognizing CSA-AKI. It also reaffi rmed CSA-AKI as a serious complication with a high incidence rate. We also confi rmed the usefulness of preoperative AKI risk prediction models such as Cleveland Clinic Score in everyday clinical practice.Uvod: Akutno bubrežno oštećenje (ABO) je ozbiljna komplikacija kardijalne kirurgije. Istraživanja su pokazala da je kardijalna kirurgija po učestalosti drugi uzrok ABO u jedinicama intenzivnog liječenja. Metode: Provedeno je retrospektivno istraživanje za razdoblje od tri godine kako bi se utvrdila incidencija ABO, odredio stupanj ozbiljnosti ABO te incidencija kontinuirane bubrežne nadomjesne terapije u bolesnika s urednom prijeoperacijskom bubrežnom funkcijom podvrgnutih kardijalnom zahvatu. U istraživanje je bilo uključeno 1000 ispitanika. Ovim istraživanjem htjeli smo potvrditi povezanost između prijeoperacijskih čimbenika rizika iz prediktivnog modela Cleveland Clinic Score i intraoperacijskih rizičnih varijabla kardijalne kirugije i anestezije s nastankom poslijeoperacijskog ABO. Sekundarni ishod je pokazao incidenciju velikih poslijeoperacijskh komplikacija u bolesnika s ABO povezanim s kardijalnim zahvatom. Rezultati: Ukupna incidencija ABO bila je 15,1 % (n=151). Učestalost ispitanika sa stadijem 1 ABO bila je 12,8 % (n=128), sa stadijem 2 1,9 % (n=19) te sa stadijem 3 0,4 % (n=4) klasifi ciranima prema kriteriju KDIGO AKI (RIFLE/AKIN). Učestalost primjene kontinuirane bubrežne nadomjesne terapije u ispitanika s ABO iznosila je 2,65 %, odnosno 0,4 % cijele kohorte ispitanika (n=4). Bolnička stopa smrtnosti bolesnika s ABO bila je 2,65% (n=4). Zanimljivo je da su svi bolesnici podvrgnuti kontinuiranoj bubrežnoj nadomjesnoj terapiji zbog ABO preživjeli. Zaključak: Ovim smo istraživanjem još jednom potvrdili važnost pravodobnog prepoznavanja poslijeoperacijskog ABO kao ozbiljne komplikacije kardijalnih zahvata. Potvrdili smo da uporaba prijeoperacijskh prediktivnih modela rizika za nastanak ABO nakon kardijalnih zahvata olakšava prepoznavanje rizičnih bolesnika i pravodobnu primjenu mjera prevencije i liječenja ABO. Najpoznatiji prediktivni model je Cleveland Clinic Score

POSTOPERATIVE HEALTH RELATED QUALITY OF LIFE AFTER CARDIAC SURGERY

Unazad četiri desetljeća opaža se smanjenje mortaliteta i morbiditeta u bolesnika nakon otvorenih i minimalno invazivnih kardijalnih zahvata. Međutim, danas glavni pokazatelj ishoda kardijalnih zahvata postaje preoperacijska kvaliteta života bolesnika. Cilj današnjih istraživanja je napraviti prediktivni model bodovanja preoperacijske kvalitete života koji bi pružio pouzdanu informaciju bolesniku i liječniku o utjecaju zahvata na funkcionalni status bolesnika i razdoblju u kojem će bolesnik postići sposobnost da istim ili boljim kapacitetom obavlja svakodnevne životne aktivnosti. Stoga uvođenje prediktivnih upitnika o preoperacijskoj kvaliteti života u svakodnevnu kliničku praksu, osobito kod starijih bolesnika, ima važnu ulogu u ranom i pravovremenom identifi ciranju bolesnika s mogućim lošijim postoperacijskim ishodom te omogućuje pravovremenu primjenu perioperacijskih mjera i postupaka radi poboljšanja kliničkog stanja bolesnika. Također, uvođenje prediktivnog modela procjene kvalitete života omogućit će bolesnicima i njihovim obiteljima bolje razumijevanje operacijskog tijeka kardiokirurškog liječenja i oporavka bolesnika, dok će liječnicima olakšati donošenje odluka o vrsti invazivnosti liječenja kod bolesnika koji se nalaze u tzv. sivoj zoni liječenja.Over the past four decades, decreasing morbidity and mortality rates of cardiac surgery patients have been noticed. However, the postoperative health-related quality of life (HRQoL) is becoming the key indicator of cardiac surgical outcome. Postoperative HRQoL is described as the impact of invasive medical procedures on functional status of patients and the ability and required time patients can proceed with their ordinary life. QoL is measured by self-report questionnaires, which according to accessible studies, are a subjective, valid, consistent and reliable way of patient QoL rating. Implementing preoperative QoL assessment in everyday practice can help in early identifying the patients with worse surgical outcome. Also, timely perioperative clinical optimization can be applied. Moreover, patients and their families are more properly informed about the consequences of cardiac procedure and its impact on the patient postoperative functional status

POSTOPERATIVE HEALTH RELATED QUALITY OF LIFE AFTER CARDIAC SURGERY

Unazad četiri desetljeća opaža se smanjenje mortaliteta i morbiditeta u bolesnika nakon otvorenih i minimalno invazivnih kardijalnih zahvata. Međutim, danas glavni pokazatelj ishoda kardijalnih zahvata postaje preoperacijska kvaliteta života bolesnika. Cilj današnjih istraživanja je napraviti prediktivni model bodovanja preoperacijske kvalitete života koji bi pružio pouzdanu informaciju bolesniku i liječniku o utjecaju zahvata na funkcionalni status bolesnika i razdoblju u kojem će bolesnik postići sposobnost da istim ili boljim kapacitetom obavlja svakodnevne životne aktivnosti. Stoga uvođenje prediktivnih upitnika o preoperacijskoj kvaliteti života u svakodnevnu kliničku praksu, osobito kod starijih bolesnika, ima važnu ulogu u ranom i pravovremenom identifi ciranju bolesnika s mogućim lošijim postoperacijskim ishodom te omogućuje pravovremenu primjenu perioperacijskih mjera i postupaka radi poboljšanja kliničkog stanja bolesnika. Također, uvođenje prediktivnog modela procjene kvalitete života omogućit će bolesnicima i njihovim obiteljima bolje razumijevanje operacijskog tijeka kardiokirurškog liječenja i oporavka bolesnika, dok će liječnicima olakšati donošenje odluka o vrsti invazivnosti liječenja kod bolesnika koji se nalaze u tzv. sivoj zoni liječenja.Over the past four decades, decreasing morbidity and mortality rates of cardiac surgery patients have been noticed. However, the postoperative health-related quality of life (HRQoL) is becoming the key indicator of cardiac surgical outcome. Postoperative HRQoL is described as the impact of invasive medical procedures on functional status of patients and the ability and required time patients can proceed with their ordinary life. QoL is measured by self-report questionnaires, which according to accessible studies, are a subjective, valid, consistent and reliable way of patient QoL rating. Implementing preoperative QoL assessment in everyday practice can help in early identifying the patients with worse surgical outcome. Also, timely perioperative clinical optimization can be applied. Moreover, patients and their families are more properly informed about the consequences of cardiac procedure and its impact on the patient postoperative functional status

Ventilator-associated pneumonia: comparing cadaveric liver transplant and non-transplant surgical patients

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes