Cijeli raspon respiracijske potpore kod trudnice s teškim oblikom infekcije COVID-19

Acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) in pregnant women can progress to a critical condition. In this paper, we present a case of a woman in the 28th week of gestation hospitalized due to respiratory insufficiency caused by COVID-19 infection and consequent bilateral pneumonia with development of severe acute respiratory distress syndrome. Noninvasive ventilation through a face mask was started but due to progression of respiratory insufficiency with high FiO2 and positive end expiratory pressure (PEEP), we decided to intubate the patient, after which obstetricians agreed to complete pregnancy by cesarean section. The clinical course was complicated by desaturation and bradycardia with recurring asystole which recovered after the use of atropine. The patient was increasingly difficult to mechanically ventilate on the PSIMV modality (tidal volume [TV] <200 mL). She was switched to ASV modality (TV up to a maximum of 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), after which peripheral saturation recovered to 89%. Due to inadequate mechanical ventilation, the patient was transferred to Dr. Fran Mihaljević University Hospital for Infectious Diseases in order to perform extracorporeal membrane oxygenation (ECMO). Owing to all of the measures taken, recovery followed after 13 days on ECMO.Akutni respiracijski sindrom uzrokovan novim koronavirusom (SARS-CoV-2) u trudnica se može komplicirati do kritičnog stanja. U ovom radu prikazujemo slučaj trudnice u 28. tjednu trudnoće hospitaliziranu zbog respiracijske insuficijencije uzrokovane infekcijom COVID-19 te posljedičnom obostranom pneumonijom i razvojem teškog ARDS-a. Započeta je neinvazivna ventilacija preko maske za lice, no zbog progresije respiracijske insuficijencije uz visoki FiO2 i PEEP odlučeno je provesti endotrahealnu intubaciju, nakon čega ginekolozi donose odluku o dovršenju trudnoće carskim rezom. Klinički tijek se komplicira desaturacijom te bradikardijom uz opetovane asistolije koje se oporave nakon primjene atropina. Bolesnicu se sve teže mehanički ventilira na modalitetu PSIMV (TV <200). Stoga je prebačena na modalitet ASV (TV do maskimalno 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), nakon čega se periferna saturacija oporavi do 89%. Zbog neodgovorajuće mehaničke ventilacije bolesnica se premješta u Kliniku za infektivne bolesti “Dr. Fran Mihaljević” zbog indicirane izvantjelesne membranske oksigenacije (ECMO). Zahvaljujući poduzetim mjerama uslijedio je oporavak nakon 13 dana ECMO-a

TAPENTADOL THERAPY IN CHRONIC PAIN MANAGEMENT: OUR EXPERIENCE

Tapentadol je novi lijek registriran u retard obliku za umjerenu i jaku kroničnu bol koji svojim spektrom djelovanja pokriva i nociceptivnu i neuropatsku komponentu boli. Analgetski se učinak postiže djelovanjem dvaju sinergističkih mehanizama: agonističkim učinkom na mi opioidne receptore (MOR-agonizam) i inhibicijom ponovnog preuzimanja noradrenalina (NRI). Cilj: Usporediti naša iskustva o učinkovitosti i podnošljivosti tapentadola s iskustvima drugih istraživača u svijetu. Metode: U istraživanje su uključena 92 bolesnika iz naše ambulante za bol, kojima je bilo indicirano propisati tapentadol-retard u dozi od dva puta 50 mg ili višoj. Pratili smo povoljni učinak na smanjenje bolova prema vizualno-analognoj ljestvici (VAS) te vrstu i učestalost neželjenih učinaka lijeka. Bilježene su i daljnje preporuke za prilagodbu doze odnosno prekid terapije. Rezultati: Pojava povoljnog djelovanja tapentadola na smanjenje kronične boli kod različitih bolnih sindroma pokazala se u 66 %, ispitanika. Postotak nuspojava, od blažih do težih, iskazalo je 43 % bolesnika. Pedeset i četiri % korisnika tapentadola odustalo je od terapije, 37 % zbog nuspojava, 15 % zbog nezadovoljstva kontrolom boli i 2 % zbog neodobravanja obiteljskog liječnika. Zaključak: Našim istraživanjem potvrđena je dobra učinkovitost tapentadola na smanjenje boli. Nuspojave se u ukupnom broju javljaju sličnom učestalošću kao u podatcima iz literature, i to rjeđe nego kod terapije klasičnim opioidima. Uočena je visoka stopa prekida terapije što je u prvom redu pripisano pojavi neželjenih učinaka.Tapentadol is a novel analgesic registered in slow-release form for medium-intensity and intense chronic pain, which targets both the nociceptive and neuropathic component of the pain signal. It utilizes two synergistic mechanisms: MOR – mu opioid receptor agonism and NRI – norepinephrine reuptake inhibition. The goal of this study was to compare the effectiveness of pain management and tolerability of tapentadol in our clinical experience with existing reports from abroad. The study included 92 patients from our pain management clinic who were prescribed slow-release tapentadol in doses of at least 50 mg twice daily. We tracked the effectiveness of pain management recorded using the visual analog scale, as well as the appearance and type of adverse effects. Further directions for dose adjustment or discontinuation of therapy were also recorded. In our experience, 66% of patients reported a satisfactory analgesic effect. The adverse effect rate was 43%; 54% of patients discontinued tapentadol therapy, i.e. 37% due to adverse effects, 15% because of inadequate pain management, and 2% because of a negative attitude of their primary care physician. Our study confi rmed the effi cacy of pain management with tapentadol. The total adverse effect rate was comparable to reports found in the literature and was lower than with classical opioid therapy. A relatively high therapy discontinuation rate was noted primarily due to adverse effects

CLINICAL CHOICE OF INTRAOPERATIVE MECHANICAL CONTROLLED VENTILATION MODE DURING GENERAL ANESTHESIA: A RETROSPECTIVE ANALYSIS AT A SINGLE CLINICAL CENTRE

Mehanička kontrolirana ventilacija je standardni postupak tijekom operacijskog zahvata u općoj anesteziji. Cilj ovog retrospektivnog istraživanja bio je prikazati naša iskustva odabira vrste mehaničke kontrolirane ventilacije za vrijeme različitih kirurških zahvata. U završnu analizu je uključeno 290 bolesnika operirano u općoj anesteziji ili kombinaciji opće i regionalne anestezije u Kliničkoj bolnici Sveti Duh u jednom mjesecu 2016. godine. Metodom slučajnog odabira za reprezentativni uzorak uzeti su bolesnici anestezirani u prosincu 2016. godine. U većini slučajeva kontrolirane intraoperacijske ventilacije koristila se volumska kontrolirana ventilacija (204 bolesnika; 70,3 %). Tlačna kontrolirana ventilacija bila je metoda odabira u 84 bolesnika (29,0 %). U jednom slučaju (0,3 %) zabilježena je kombinacija tlačne i volumske kontrolirane ventilacije. Također u jednom slučaju (0,3 %) zabilježena je manualna kontrolirana ventilacija. Medijan zadanog disajnog volumena pri volumskoj kontroliranoj ventilaciji bio je 525 mL (500-575 mL, interkvartilni raspon). Medijan zadane frekvencije disanja u minuti pri volumskoj kontroliranoj ventilaciji bio je 12 (12-12, interkvartilni raspon). Medijan zadanog tlaka upuhivanja pri tlačnoj kontroliranoj ventilaciji bio je 14 cm H2O (11-16 cm H2O, interkvartilni raspon). Medijan zadane frekvencije disanja u minuti pri tlačnoj kontroliranoj ventilaciji bio je 12 (12-13, interkvartilni raspon). Prigodom volumski kontrolirane ventilacije parametri zadanog volumena udisanja prilagođavali su se u 37 slučajeva (18,1 %), a frekvencija u 75 (36,8 %). Prigodom tlačne kontrolirane ventilacije parametri zadanog tlaka udisanja su se prilagođavali u 30 slučajeva (35,7 %), a frekvencija u 24 (28,6 %). Prilagodba parametra frekvencije bila je značajno češća prilikom volumski kontrolirane ventilacije (P<0,001). Rezultati ovog istraživanja pokazuju da se tijekom kirurških zahvata u općoj anesteziji i dalje češće koristi tradicionalna volumski kontrolirana ventilacija koja zahtijeva veći angažman anesteziologa u smislu korekcije zadane frekvencije disanja da bi se postigle ciljane intraoperacijske vrijednosti parametara ventilacije.Mechanical controlled ventilation is a standard intraoperative procedure during general anesthesia. The aim of this retrospective study was to present our experience of selecting the mode of mechanical controlled ventilation during different surgical procedures. Final analysis included 290 surgical patients in general anesthesia or a combination of general and regional anesthesia at the Sveti Duh University Hospital in one-month period during 2016. Random method for a representative sample was used to select the patients anaesthetized during December 2016. Volume controlled ventilation (204 patients, 70.3%) was the most frequently used mode of controlled intraoperative ventilation. Pressure controlled ventilation was used in 84 (29.0%) patients. The combination of volume- and pressure-controlled ventilation and manually controlled ventilation were used in one case (0.3%) each. The median of tidal volume during volume controlled ventilation was 525 mL (500-575 mL, interquartile range), with the median of breathing rate per minute 12 (interquartile range, 12-12). The median inspiratory pressure during pressure controlled ventilation was 14 cm H2O (11-16 cm H2O, interquartile range), with the median of breathing rate per minute 12 (12-13, interquartile range). During volume controlled ventilation, tidal volumes were adjusted in 37 (18.1%) and the rates in 75 (36.8%) cases. During pressure controlled ventilation, the inspiratory pressure parameters were adjusted in 30 (35.7%) and the rates in 24 (28.6%) cases. Adjustment of the breathing rate parameter was signifi cantly more frequent in volume controlled ventilation (p<0.001). The results of this study demonstrate that during surgery under general anesthesia, we still more often use the traditional volume controlled ventilation that requires more anesthesiologist’s engagement in adjusting breathing rate to reach the target intraoperative ventilation parameters

CLINICAL CHOICE OF INTRAOPERATIVE MECHANICAL CONTROLLED VENTILATION MODE DURING GENERAL ANESTHESIA: A RETROSPECTIVE ANALYSIS AT A SINGLE CLINICAL CENTRE

Mehanička kontrolirana ventilacija je standardni postupak tijekom operacijskog zahvata u općoj anesteziji. Cilj ovog retrospektivnog istraživanja bio je prikazati naša iskustva odabira vrste mehaničke kontrolirane ventilacije za vrijeme različitih kirurških zahvata. U završnu analizu je uključeno 290 bolesnika operirano u općoj anesteziji ili kombinaciji opće i regionalne anestezije u Kliničkoj bolnici Sveti Duh u jednom mjesecu 2016. godine. Metodom slučajnog odabira za reprezentativni uzorak uzeti su bolesnici anestezirani u prosincu 2016. godine. U većini slučajeva kontrolirane intraoperacijske ventilacije koristila se volumska kontrolirana ventilacija (204 bolesnika; 70,3 %). Tlačna kontrolirana ventilacija bila je metoda odabira u 84 bolesnika (29,0 %). U jednom slučaju (0,3 %) zabilježena je kombinacija tlačne i volumske kontrolirane ventilacije. Također u jednom slučaju (0,3 %) zabilježena je manualna kontrolirana ventilacija. Medijan zadanog disajnog volumena pri volumskoj kontroliranoj ventilaciji bio je 525 mL (500-575 mL, interkvartilni raspon). Medijan zadane frekvencije disanja u minuti pri volumskoj kontroliranoj ventilaciji bio je 12 (12-12, interkvartilni raspon). Medijan zadanog tlaka upuhivanja pri tlačnoj kontroliranoj ventilaciji bio je 14 cm H2O (11-16 cm H2O, interkvartilni raspon). Medijan zadane frekvencije disanja u minuti pri tlačnoj kontroliranoj ventilaciji bio je 12 (12-13, interkvartilni raspon). Prigodom volumski kontrolirane ventilacije parametri zadanog volumena udisanja prilagođavali su se u 37 slučajeva (18,1 %), a frekvencija u 75 (36,8 %). Prigodom tlačne kontrolirane ventilacije parametri zadanog tlaka udisanja su se prilagođavali u 30 slučajeva (35,7 %), a frekvencija u 24 (28,6 %). Prilagodba parametra frekvencije bila je značajno češća prilikom volumski kontrolirane ventilacije (P<0,001). Rezultati ovog istraživanja pokazuju da se tijekom kirurških zahvata u općoj anesteziji i dalje češće koristi tradicionalna volumski kontrolirana ventilacija koja zahtijeva veći angažman anesteziologa u smislu korekcije zadane frekvencije disanja da bi se postigle ciljane intraoperacijske vrijednosti parametara ventilacije.Mechanical controlled ventilation is a standard intraoperative procedure during general anesthesia. The aim of this retrospective study was to present our experience of selecting the mode of mechanical controlled ventilation during different surgical procedures. Final analysis included 290 surgical patients in general anesthesia or a combination of general and regional anesthesia at the Sveti Duh University Hospital in one-month period during 2016. Random method for a representative sample was used to select the patients anaesthetized during December 2016. Volume controlled ventilation (204 patients, 70.3%) was the most frequently used mode of controlled intraoperative ventilation. Pressure controlled ventilation was used in 84 (29.0%) patients. The combination of volume- and pressure-controlled ventilation and manually controlled ventilation were used in one case (0.3%) each. The median of tidal volume during volume controlled ventilation was 525 mL (500-575 mL, interquartile range), with the median of breathing rate per minute 12 (interquartile range, 12-12). The median inspiratory pressure during pressure controlled ventilation was 14 cm H2O (11-16 cm H2O, interquartile range), with the median of breathing rate per minute 12 (12-13, interquartile range). During volume controlled ventilation, tidal volumes were adjusted in 37 (18.1%) and the rates in 75 (36.8%) cases. During pressure controlled ventilation, the inspiratory pressure parameters were adjusted in 30 (35.7%) and the rates in 24 (28.6%) cases. Adjustment of the breathing rate parameter was signifi cantly more frequent in volume controlled ventilation (p<0.001). The results of this study demonstrate that during surgery under general anesthesia, we still more often use the traditional volume controlled ventilation that requires more anesthesiologist’s engagement in adjusting breathing rate to reach the target intraoperative ventilation parameters

ANALYSIS OF PATIENTS WITH ACUTE RENAL FAILURE HOSPITALIZED AT DEPARTMENT OF NEPHROLOGY AND DIALYSIS, RIJEKA UNIVERSITY HOSPITAL, DURING THE FIVE-YEAR PERIOD

Akutno bubrežno zatajenje (ABZ) javlja se u 5 % do 18 % hospitaliziranih bolesnika, a i do 30 % u jedinicama intenzivne skrbi. Cilj naše studije bio je analizirati incidenciju i uzroke ABZ u našem Centru tijekom petogodišnjeg razdoblja, analizirati karakteristike bolesnika i njihovih komorbidnih stanja te varijacije u laboratorijskim parametrima, duljinu hospitalizacije, primijenjenu terapiju i ishod liječenja. Tijekom petogodišnjeg razdoblja analizirali smo 316 bolesnika koji su zbog razvoja ABZ bili hospitalizirani na Zavodu za nefrologiju i dijalizu, KBC Rijeka. Podaci su dobiveni pretraživanjem medicinske dokumentacije. ABZ je bio uzrok u 8,2 % do 9,9 % hospitaliziranih bolesnika. Nije bilo statistički značajne razlike u spolu i dobi bolesnika, iako je vidljiv trend porasta starije populacije. Uzrok ABZ bio je najčešće prerenalne etiologije (56,1 % do 67,9 %). Najveći broj bolesnika bio je liječen konzervativnim mjerama (52,6 % do 71,4 %), a liječenje dijalizom bilo je potrebno u 12,5 % do 21,1 % bolesnika. Do smrtnog ishoda došlo je od 21,2 % do 30,4 % bolesnika, dok je potpuni oporavak bio u 30,5 % do 40,4 % bolesnika. Prosječna duljina hospitalizacije kretala se od 11,8 do 15,1 dana. Zaključuje se da je ABZ značajan uzrok hospitalizacije bolesnika. Nužno je rano prepoznavanje bolesti i adekvatno rano liječenje u cilju poboljšanja preživljenja, ali i poboljšanja oporavka bubrežne funkcije.Introduction: Acute renal failure (ARF) is a serious complication that occurs in 5%-18% of hospitalized patients and in up to 30% of patients admitted to Intensive Care Unit. The hospital mortality rate of patients with ARF is between 28% and 90%. The incidence of ARF is proportional to patient age. Therefore, despite all improvements in modern medicine, the annual incidence of ARF has not changed over the two past decades. The aim of our study was to analyze the incidence and causes of ARF in our Center during the five-year period, to analyze the characteristics of patients and their comorbid conditions, variations in laboratory parameters during hospitalization, and therapy administered. Also, we analyzed the outcome and length of hospitalization. Subjects and Methods: During the five-year period (from January 2008 till December 2012), we analyzed 316 patients treated for ARF at Department of Nephrology and Dialysis, Rijeka University Hospital Center. Data were obtained by searching medical records. ARF was defined according to the KDIGO recommendations: increase in serum creatinine (sCR) >26 μmol/L within 48 h, or increase in sCR by 1.5 times compared to the reference values , which is known or assumed to have appeared within a week of hospitalization, or diuresis <0.5 mL/kg/h for ≥6 hours. Results: Out of 316 ARF patients analyzed, 57 were hospitalized at our Department in 2008 (50.9% of men and 49.1% of women), 56 in 2009 (39.3% of men and 60.7% of women), 66 in 2010 (55.3% of men and 44.7% of women) and 76 in 2011 (55.3% of men and 44.7% of women). In 2012, we analyzed 61 ARF patients (42.6% of men and 53.4% of women). There were no statistically significant age and gender differences, although we noticed an increasing tendency in the number of elderly patients hospitalized for ARF. Furthermore, analyzing the frequency of patient arrival from home, nursing home or transfer from other departments we recorded an increase in the arrival of patients from nursing homes during the study period. Analysis of the proportion of patients hospitalized for ARF in our Department in relation to the total number of hospitalized patients revealed that ARF was the cause of hospitalization in 8.2%-9.9% of all patients. There was no significant change in the number of patients hospitalized for ARF during the period observed. Analyzing the frequency of hospitalization due to ARF by months, we noticed that the largest number of patients were hospitalized during summer months (from June to September). The most common form of ARF was prerenal (56.1%-67.9%). The largest number of patients were treated by parenteral rehydration and antibiotics (52.6%-71.4%). Renal replacement therapy was performed in 12.5%-21.1% of all patients. The mortality rate throughout the period of observation ranged from 21.2%-30.4%. Furthermore, complete recovery of renal function was achieved in 30.5%-40.4% of all patients. The mean length of hospital stay ranged from 11.8 to 15.1 days. Conclusion: Acute renal failure is a significant cause of hospitalization, especially in elderly patients. Therefore, early identification along with appropriate and early treatment of patients with ARF is needed to improve survival and recovery of renal function in these patients

TAPENTADOL THERAPY IN CHRONIC PAIN MANAGEMENT: OUR EXPERIENCE

Tapentadol je novi lijek registriran u retard obliku za umjerenu i jaku kroničnu bol koji svojim spektrom djelovanja pokriva i nociceptivnu i neuropatsku komponentu boli. Analgetski se učinak postiže djelovanjem dvaju sinergističkih mehanizama: agonističkim učinkom na mi opioidne receptore (MOR-agonizam) i inhibicijom ponovnog preuzimanja noradrenalina (NRI). Cilj: Usporediti naša iskustva o učinkovitosti i podnošljivosti tapentadola s iskustvima drugih istraživača u svijetu. Metode: U istraživanje su uključena 92 bolesnika iz naše ambulante za bol, kojima je bilo indicirano propisati tapentadol-retard u dozi od dva puta 50 mg ili višoj. Pratili smo povoljni učinak na smanjenje bolova prema vizualno-analognoj ljestvici (VAS) te vrstu i učestalost neželjenih učinaka lijeka. Bilježene su i daljnje preporuke za prilagodbu doze odnosno prekid terapije. Rezultati: Pojava povoljnog djelovanja tapentadola na smanjenje kronične boli kod različitih bolnih sindroma pokazala se u 66 %, ispitanika. Postotak nuspojava, od blažih do težih, iskazalo je 43 % bolesnika. Pedeset i četiri % korisnika tapentadola odustalo je od terapije, 37 % zbog nuspojava, 15 % zbog nezadovoljstva kontrolom boli i 2 % zbog neodobravanja obiteljskog liječnika. Zaključak: Našim istraživanjem potvrđena je dobra učinkovitost tapentadola na smanjenje boli. Nuspojave se u ukupnom broju javljaju sličnom učestalošću kao u podatcima iz literature, i to rjeđe nego kod terapije klasičnim opioidima. Uočena je visoka stopa prekida terapije što je u prvom redu pripisano pojavi neželjenih učinaka.Tapentadol is a novel analgesic registered in slow-release form for medium-intensity and intense chronic pain, which targets both the nociceptive and neuropathic component of the pain signal. It utilizes two synergistic mechanisms: MOR – mu opioid receptor agonism and NRI – norepinephrine reuptake inhibition. The goal of this study was to compare the effectiveness of pain management and tolerability of tapentadol in our clinical experience with existing reports from abroad. The study included 92 patients from our pain management clinic who were prescribed slow-release tapentadol in doses of at least 50 mg twice daily. We tracked the effectiveness of pain management recorded using the visual analog scale, as well as the appearance and type of adverse effects. Further directions for dose adjustment or discontinuation of therapy were also recorded. In our experience, 66% of patients reported a satisfactory analgesic effect. The adverse effect rate was 43%; 54% of patients discontinued tapentadol therapy, i.e. 37% due to adverse effects, 15% because of inadequate pain management, and 2% because of a negative attitude of their primary care physician. Our study confi rmed the effi cacy of pain management with tapentadol. The total adverse effect rate was comparable to reports found in the literature and was lower than with classical opioid therapy. A relatively high therapy discontinuation rate was noted primarily due to adverse effects