ACUTE RESPIRATORY DISTRESS SYNDROME AND OTHER RESPIRATORY DISORDERS IN SEPSIS

Akutni respiracijski distresni sindrom (ARDS) se uobičajeno razvija u bolesnika s prisutnim rizičnim čimbenicima (npr. sepsa, pneumonija, akutni pankreatitis, politrauma, višestruke transfuzije krvi i krvnih pripravaka i sl.) koji aktiviraju sustavni upalni odgovor. Sepsa je jedan od najčešćih čimbenika koji može dovesti do razvoja ARDS-a. ARDS povezan sa sepsom pokazuje sporiji oporavak plućne funkcije uz manju uspješnost odvajanja bolesnika od strojne ventilacije. Vrlo je važno uz sve ostale mjere liječenja sepse obratiti posebnu pozornost optimalizaciji strojne respiracijske potpore u skladu s trenutnim stanjem pluća. Svake je godine dostupno sve više podataka o mogućnostima liječenja bolesnika s ARDS-om uz pomoć posebno prilagođenih načina strojne ventilacije pri čemu važnu ulogu imaju: izbor optimalnog poštednog modaliteta, primjena potpomognute ventilacije i adekvatno podešavanje pozitivnog tlaka na kraju izdaha (engl. positive end-expiratory pressure - PEEP). Međutim, što iz ovih eksperimentalnih i kliničkih podataka možemo prenijeti u svakodnevnu kliničku praksu? U ovom članku izneseni su načini adekvatne prilagodbe poštedne ventilacije kao mjere s dokazanim učinkom na smanjenje mortaliteta ove skupine bolesnika ako se sustavno i dosljedno primjenjuje.Acute respiratory distress syndrome (ARDS) develops in patients with predisposing conditions that induce systemic infl ammatory response such as sepsis, pneumonia, acute pancreatitis, major trauma, or multiple transfusions. Sepsis is the most common cause of ARDS. Sepsis-related ARDS patients have signifi cantly lower PaO2 /FiO2 ratios than patients with non-sepsis-related ARDS. Furthermore, their recovery from lung injury is prolonged, weaning from mechanical ventilation less successful, and extubation rate slower. Clinical outcomes in patients with sepsis-related ARDS are also worse, associated with signifi cantly higher 28-day and 60-day mortality rates (31.1% vs. 16.3% and 38.2% vs. 22.6%, respectively). It is extremely important to optimally adjust ventilator setting to current condition of lungs, while providing all other therapeutic measures in the treatment of sepsis, severe sepsis and septic shock. The pool of data on treatment possibilities for patients with ARDS grows every year, with specifi cally designed mechanical ventilation strategies. Ventilator modes and adequate positive end-expiratory pressure (PEEP) settings play a major role in these strategies. However, how can we best apply these experimental and clinical data to everyday clinical practice? This article emphasizes protective ventilation as a measure that is proven to reduce mortality in this group of patients, when systematically and consistently applied

Nonelective surgery at night and in-hospital mortality - Prospective observational data from the European Surgical Outcomes Study

BACKGROUND Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION None. MAIN OUTCOME MEASURES Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed