Incidence of central diabetes insipidus in brain dead patients

Antidiuretic hormone (ADH), also called arginine vasopressin, is a hypothalamus-produced hormone stored and secreted in the posterior pituitary gland. When concentration of extracellular fluid increases, fluid leaks from hypothalamic osmoreceptor cells, creating a signal for ADH secretion. ADH is responsible for water retention in the kidneys. In brain dead patients, lack of ADH production occurs. Plasma half-life of ADH is 15-18 minutes. Therefore, full depletion of ADH should be expected soon after brain death, causing central diabetes insipidus (CDI). The aim of the study was to show incidence of CDI in brain dead patients. Data of patients with verified brain death at Sestre milosrdnice University Hospital Center in Zagreb from 2015 to 2018 were analysed. Poliuria, low urine specific gravity, hypernatriemia and response to desmopressin were criteria for CDI. In four year time period, 89 patients were verfied as brain dead. Out of them, 71 (79.8%) developed CDI. CDI was expected in all patients with defined brain death. However, only 79.8% of them developed CDI. One possible explanation may be preserved function of hypothalamic osmoregulation system in some patients. Parts of hypophisis and hypothalamus may stay sufficiently perfused by arteria hypophisialis inferior, which branches off extradural segment of arteria carotis interna, and is therefore protected from increased intracranial pressure. Other, less likely possibilities are presence of extracranial tumor with ADH secretion or passive ADH leakage from non-viable hypothalamic cells

Zbrinjavanje otežanog dišnog puta u Kliničkom bolničkom centru “Sestre milosrdnice”

Difficult airway has gained increasing interest due to a relatively high number of adverse effects following unsuccessful intubation. Besides traditional techniques, several alternative methods are available today. It is crucial for the anesthesiologists and intensive care physicians to maintain sufficient oxygenation and ventilation of the patient. Hypoxia is one of the most frequent causes of death or severe neurologic defects in anesthesia. Therefore, it is necessary to have an easy alternative to secure the airways in critical situations.Otežani dišni put izaziva sve veće zanimanje zbog relativno velikog broja različitih rezultata nastalih neuspješnom intubacijom. Uz tradicionalne tehnike danas na tržištu postoje i alternativne metode. Veoma je važno za anesteziologa i liječnika u Jedinici intenzivnog liječenja održavanje dostatne ventilacije i oksigenacije u bolesnika. Hipoksija je jedan od najčešćih uzroka smrti ili neuroloških ispada u anesteziji. Stoga je iznimno važno imati alternativno rješenje zbrinjavanja otežanog dišnog puta u hitnim stanjima

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

Early complications of percutaneous tracheostomy using the Griggs method

This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods

Trend and development of epidural analgesia and epidural anesthesia in the maternitiy ward of UHC Sestre milosrdnice over the past ten years

Tijekom posljednjih godina epiduralna analgezija za obezboljavanje vaginalnog porođaja primjenjuje se sve češće i jedna je od najčešće rabljenih regionalnih tehnika. Epiduralna anestezija uglavnom se rabi za hitni carski rez u rodilja koje već imaju postavljen epiduralni kateter za epiduralnu analgeziju tijekom vaginalnog porođaja. U rodilištu Kliničkoga bolničkog centra Sestre milosrdnice proveli smo retrospektivnu kohortnu studiju od 2008. do 2018. godine. Proučavali smo desetogodišnji trend incidencije epiduralne analgezije u odnosu prema ukupnom broju porođaja i incidencije epiduralne anestezije za hitni carski rez u odnosu prema ukupnom broju hitnih carskih rezova. U 2008. godini učestalost epiduralne analgezije u odnosu prema ukupnom broju porođaja bila je 21% (662/3125), a u 2018. godini 34% (1059/3083). U 2008. godini broj epiduralnih anestezija u odnosu prema ukupnom broju anestezija za hitni carski rez bio je 9% (51/552), a u 2018. 27% (172/639). Trend porasta vidljiv je kod obaju postupaka i iznosi 13% za epiduralne analgezije i 18% pri epiduralnim anestezijama.Over the years, epidural analgesia for pain relief of vaginal delivery is increasingly being applied and is one of the most frequently used regional techniques. Epidural anesthesia is mainly used in emergency cesarean section in parturients who already have an epidural catheter for epidural analgesia during vaginal delivery. In the delivery ward at the Sestre milosrdnice University Hospital Center we have conducted a retrospective cohort study from 2008 to 2018.We studied the incidence of epidural analgesia in relation to the total number of births and the incidence of epidural anesthesia for emergency cesarean section in relation to the total number of emergency cesarean sections. In 2008, the incidence of epidural analgesia in the relation to the total number of births was 21% (662/3125),and in 2018 it was 34% (1059/3083). In 2008, the number of epidural anesthesia for emergency cesarean section in the relation to the total number of emergency cesarean sections was 9% (51/552), andn in 2018 it was 27% (172/639). An increasing trend is seen in both procedures and is 13% for epidural analgesiaand 18% for epidural anesthesia

Anesthesia and analgesia for FAUCS technique of cesarean section – case report

Carski rez povezan je s povećanim brojem komplikacija i velikom postoperativnom boli koja uzrokuje produljenje oporavka za tri do pet dana u odnosu prema vaginalnom porođaju. Novijom kirurškom metodom FAUCS (engl. French Ambulatory Cesarean Section) smanjuju se poslijeoperacijske komplikacije i bolnost. U Klinici za ženske bolesti i porodništvo Kliničkoga bolničkog centra Sestre milosrdnice u Zagrebu započelo se primjenjivati ovu operacijsku metodu u ožujku 2019. godine, prvi put u Hrvatskoj. Spinalna (subarahnoidalna) anestezija jest anestezija izbora za ovakav zahvat zbog potrebe sudjelovanja rodilje pri ekstrakciji novorođenčeta. Bolnost je zahvata manja, stoga spinalna anestezija iziskuje nižu dozu lokalnog anestetika u odnosu prema uobičajenoj standardnoj dozi za carski rez. Sniženje doze lokalnog anestetika omogućuje brži oporavak motoričke funkcije, a samim time i bržu mobilizaciju rodilje. Uz spinalnu anesteziju kombinira se analgezija blokom ravnine transversusa abdominis (engl. Transversus abdominis plane – TAP block) na kraju zahvata. Blok TAP-a doveo je do potpunog uklanjanja boli tijekom prva 24 poslijeoperacijska sata. Potreba za medikamentnom terapijom boli smanjena je na najmanju moguću, a opioidni analgetici nisu bili potrebni. Ovakva kombinacija poštednijega carskog reza i regionalne analgezije omogućila je brži oporavak rodilje, što je povezano s brojnim dobrobitima i za majku i za dijete. Donosimo prikaz jedne od prvih primjena metode FAUCS uz spinalnu anesteziju i blok TAP-a u Hrvatskoj.Cesarean section is correlated with a higher number of complications and higher postoperative pain which prolongs recovery in comparison with vaginal delivery for three to five days. With a relatively new and advanced surgical technique French Ambulatory Cesarean section (FAUCS) there are fewer postoperative complications and lower pain scores. In our Clinical Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, we started with this surgical technique at the beginning of 2019 for the first time in Croatia. The choice of anesthesia for this procedure is spinal anesthesia because the cooperation of the patient is essential for successful extraction of the neonate. As this procedure is less painful it is possible to reduce the dosage of spinal local anesthetic in comparison with the usual dose for classical cesarean section. Lower local anesthetic dose enables faster recovery of motor function, and allows faster mobilization of the parturients. We combined spinal anesthesia with Trans-Abdominal Plain (TAP) block at the end of the procedure. TAP block led to the complete elimination of postoperative pain during the first 24 postoperative hours. The necessity for pain medication therapy after day one was reduced to minimal doses, and opiate analgesics were not used. This combination of less painful cesarean section and regional anesthesia enabled faster patient recovery with many benefits for the woman and the newborn. In this case report we present one of our first cases

Oxidative Stress Reduction by Midazolam Premedication during Oocyte Retrieval Procedure: Pilot Study

Infertility is one of the major medical problems nowadays. Couples who opt for In Vitro Fertilization (IVF) face a great deal of stress which certainly affects the outcome of the procedure. Therefore, we aimed to reduce the stress during the oocyte retrieval procedure by applying midazolam. Total oxidant (TOC) and antioxidant (TAC) capacities of serum, as well as glutathione (GSH) content and catalase activity, were measured in both control and midazolam groups. Follicular fluid was also tested for oxidant capacity and IL1β. Results implied that the midazolam group increased TAC at the end of the procedure. At the same time, the control group decreased GSH at the beginning of the procedure, and both groups decreased catalase activity at the end of the procedure. The results imply that stress during the procedure affects oxidative and antioxidative parameters of the patients, but did not affect the frequency of the pregnancy at the end of this pilot study. Yet, the results imply that oxidative and antioxidative mechanisms during IVF should be investigated in detail as they could affect the outcome of IVF

Early complications of percutaneous tracheostomy using the Griggs method

This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods

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

Preporuke za perioperacijski postupak kod bolesnika koji imaju ugrađene kardiovaskularne implantabilne elektroničke uređaje

Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients.U Republici Hrvatskoj na godinu se implantira oko 4000 kardiovaskularnih implantabilnih uređaja i taj broj je u stalnom porastu. Anestezija i kirurški zahvati kod bolesnika s ugrađenim implantabilnim uređajima nose određene rizike. Ove smjernice su nastale zato što se većina zahvata izvodi u ustanovama bez mogućnosti testiranja i reprogramiranja navedenih uređaja ili u vrijeme kada to nije dostupno. Cilj je standardizirati perioperacijsku skrb ovih bolesnika te učiniti kirurške zahvate dostupnima i sigurnima za veliku većinu ovih kirurških bolesnika u svim ustanovama u Hrvatskoj