Usporedba rane i kasne perkutane traheotomije u kritično bolesnih: retrospektivna opservacijska studija u jednom centru

Despite decades of experience in tracheotomy, there still exists a controversy over its ideal timing. The aim of our study was to compare the impact of early and late percutaneous tracheotomy in terms of their ability to reduce mechanical ventilation duration and length of stay in Intensive Care Unit, as well as the frequency of ventilator-associated pneumonia and mortality rates in tracheotomized patients. This retrospective observational study indicated that early tracheotomy in surgical and neurosurgical patients was associated with a reduced duration of mechanical ventilation and reduced length of stay in Intensive Care Unit, but was unable to reduce the frequency of ventilator-associated pneumonia and mortality. The reason behind the shorter duration of mechanical ventilation and shorter length of stay in Intensive Care Unit in the early tracheotomy arm was shorter duration of mechanical ventilation carried out prior to tracheotomy, while the duration of mechanical ventilation and the length of stay in Intensive Care Unit after tracheotomy were similar in both groups, suggesting that the procedure itself and not its timing influenced the duration of mechanical ventilation and the length of stay in Intensive Care Unit of tracheotomized patients.Traheotomija je vrlo čest postupak koji se izvodi kod bolesnika koji zahtijevaju produženu mehaničku ventilaciju. Unatoč desetljećima iskustva u izvođenju traheotomije još uvijek postoje dileme o idealnom vremenu izvođenja. Cilj ovoga istraživanja je bio usporedba rane i kasne traheotomije s obzirom na njihov utjecaj na trajanje mehaničke ventilacije i duljinu boravka u Jedinici intenzivnog liječenja, kao i na učestalost pojave ventilacijske pneumonije i smrtnost među traheotomiranim bolesnicima. Istraživanje je provedeno u 15-krevetnoj Jedinici intenzivnog liječenja Odjela za anesteziologiju, reanimatologiju i intenzivno liječenje u Kliničkom bolničkom centru “Sestre milosrdnice”, Zagreb, Hrvatska. Podaci su skupljani retrospektivno od rujna 2009. do ožujka 2013. godine. U istraživanje su bili uključeni samo bolesnici perkutano traheotomirani tijekom navedenog razdoblja. Rezultati ovoga istraživanja ukazuju na to da rana traheotomija skraćuje trajanje mehaničke ventilacije i duljinu boravka u Jedinici intezivnog liječenja, dok na učestalost ventilacijske pneumonije i smrtnost nema utjecaja. Razlog kraćeg trajanja mehaničke ventilacije i kraćeg boravka u Jedinici intezivnog liječenja je kraće trajanje mehaničke ventilacije prije izvođenja traheotomije, dok je trajanje mehaničke ventilacije nakon traheotomije bilo slično u obje skupine, što upućuje na zaključak da sam postupak traheotomije, a ne vrijeme izvođenja utječe na trajanje mehaničke ventilacije i duljinu boravka u Jedinici intenzivnog liječenja

Nerazmjer između podataka za intrakranijski i cerebralni perfuzijski tlak te neuroloških nalaza u bolesnika s teškom ozljedom glave: prikaz slučaja

A 48-year-old man with relative hepatic impairment, thrombocytopenia and chronic alcoholism was admitted to intensive care unit six hours after head trauma. Computed tomography (CT) scan at admission indicated cerebral edema and subdural hematoma. Glasgow Coma Score (GCS) was 5, and his pupils were 4 mm in diameter without response. Decompression craniotomy with evacuation of hematoma was performed, and a ventricular catheter was introduced for intracranial pressure (ICP) monitoring. After the operation, there was no change in the neurologic status. ICP/CPP and jugular vein oxygen saturation (SvjO2) were continuously monitored and data were collected in hour-to-hour manner. Therapeutic goal was to optimize ICP and cerebral perfusion pressure (CPP) in accordance with the Guidelines for the Management of Severe Head Injury. Mannitol and barbiturates were not used in therapeutic procedures. Normocapnic values of PCO2 were maintained. During the first six hours postoperatively, the patient was stabilized hematologically and hemodynamically. At 24 hours postoperatively, there was no improvement in the neurologic status in spite of optimal values of ICP/CPP and SvjO2: GCS 5, pupils 4 mm with no response. The reason for this was detected on 24-hour CT scan, which revealed thalamic and pontine hemorrhage (mesencephalon lesion) with ischemia in the occipital region.Muškarac star 48 godina s relativnim oštećenjem jetre, trombocitopenijom i kroničnim alkoholizmom u anamnezi primljen je u jedinicu intenzivnog liječenja šest sati nakon ozljede glave. Nalaz kompjutorizirane tomografije (CT) kod prijma pokazao je subduralni hematom i edem mozga. Kod primitka, Glasgow Coma Score (GCS) bio je 5, zjenice 4 mm izokorične i nereaktivne. Učinjena je dekompresijska kraniotomija s evakuacijom hematoma, te je postavljen kateter za mjerenje intrakranijskog tlaka (ICP). Kontinuirano su mjereni ICP, cerebralni perfuzijski tlak (CPP), zasićenje jugularne vene kisikom (Svj O2) i CO2. Nakon 24 sata nije došlo do neurološkog poboljšanja unatoč tome što su postignute željene terapijske vrijednosti svih praćenih parametara. Kontrolni CT mozga pokazao je krvarenje u ponsu i talamusu, te ishemiju okcipitalno, zbog čega je izostalo poboljšanje neurološkog statusa. Kasna dijagnostika i nedostupnost za terapiju dubokih i infratentorijalnih ozljeda mozga problem su u svakodnevnom liječenju ovih bolesnika

Construction project management activity in the Republic of Croatia: analysis of the current situation

U radu se analizira stanje područja primjene djelatnosti upravljanja projektom gradnje u RH (DUPG) koje, iako u primjeni već sedmu godinu, još uvijek nije rezultiralo ujednačenim pristupom javnih i sektorskih naručitelja. Identificirana su sljedeća ograničenja i nedorečenosti u zakonskoj platformi za DUPG: neusklađena terminologija, međusobna neusklađenost propisa, preklapanja u ovlastima i dužnostima nadzora/(FIDIC) inženjera i voditelja projekta (VP), nedovoljno precizne prekršajne odredbe te izostanak pravodobnog uključivanja VP-a u projekt kao posljedica nerazumijevanja njegovog utjecaja na uspješnost graditeljskog projekta od strane javnih i sektorskih naručitelja. Međutim, kroz prikaz dobrih praksi i uvida u međunarodne norme, obrazlaže se način za dodatnim standardiziranjem zasad neusklađene i u određenim dijelovima podregulirane materije kao i potreba za njezinim dereguliranjem. Zaključno su u radu obrazložene smjernice za daljnje standardiziranje DUPG-a i usklađivanje postojećih propisa s ciljem održivosti i učinkovitosti projekata.This study analyses the current state of the activities of construction project management in the Republic of Croatia (CPM), which, although in the seventh year of existence, still does not have a uniform approach for public contracting authorities/entities. Limitations and ambiguities in the legal platform for CPM have been identified: inconsistent terminology, mutual inconsistency of regulations, overlap of authority and duties of the supervision/(FIDIC) Engineer and project manager (PM), insufficient precision of misdemeanour provisions, and lack of timely involvement of PM in the project as a consequence of misunderstanding, by the public contracting authorities/entities, of the importance of the influence of PM on the success of the construction project. However, the presentation of good practices and insight into international standards illustrates the need for additional standardisation of currently certain aspects of uncoordinated and sub-regulated areas, and the simultaneous need for deregulation. In conclusion, this study provides guidelines for the further standardisation of DUPG and harmonisation of existing regulations for sustainable and efficient projects

Distribution center logistics optimization model – City of Rijeka case study

The optimization of the goods delivery to Rijeka’s city center presents a complex organizational framework where many parameters must be taken into account and a diverse multi-methodological approach, needs to be utilized. The building of a distribution center is asserted here to be one notable way to improve the existing delivery service. The grouping of freight in a distribution center would result in a reduction of transport costs due to a smaller number of vehicles entering the city center, in turn reducing the traffic burden incumbent on the city’s transport network. In this paper, two of the many possible methods related to the optimization of goods delivery in city centers, have been used. Based on the data collected through the study’s questionnaire, conducted in the area of the city of Rijeka, the method of gravity center has been used to determine the location of the distribution center. Then, based on the tentative location of the distribution center, the method of optimization of the transport process has been applied by resorting to transport problem-solving methods, including several different implementation scenarios. From the proposed solutions, and based on the results detailed, the solution that was found to be the most credible was arguably the best match with the default criterion

Integrating Maritime National Single Window with Port Community System – Case Study Croatia

A single point of data entry for documentary requirements and procedures in maritime transport - Maritime National Single Window (MNSW) includes process integration of all stakeholders in the entire seaport system. The primary goal of the MNSW is to eliminate data redundancy in a way that the entered data is instantly visible in other systems, according to the set level of authorization and authentication. In many seaports, the administrative MNSW is connected to the commercial Port Community System (PCS), an information system for the exchange of cargo related commercial data. The linking of the MNSW and the PCS connects the administrative with the commercial business aspect, making seaport business processes more efficient and more effective. Both interfaces can only be developed by using process reengineering and presume significant investments in underlying information technologies. Such implementation requires in-depth analysis of all stakeholders’ processes in the seaport system, in order for both systems to complement each other

Mikrobiološki profil i antibiotska osjetljivost uzročnika ventilacijske pneumonije u Jedinici intenzivnog liječenja Kliničkog bolničkog centra "Sestre milosrdnice", Zagreb, Hrvatska

Ventilator-associated pneumonia (VAP) is very common in many intensive care Units, but there are still many uncertainties about VAP, especially about the choice of initial empiric antibiotics. The incidence of specific pathogens with different susceptibility patterns causing VAP varies from hospital to hospital. This is the reason why empiric initial antibiotic treatment for VAP should be based not only on general guidelines (that recommend therapy according to the presence of risk factors for multidrug-resistant bacteria), but also on up-to-date information on local epidemiology. The aim of this study was to determine the microbial profile of pathogens causing VAP and their antibiotic susceptibility patterns. The study was conducted in the 15-bed surgical and neurosurgical Intensive Care Unit, Department of Anesthesiology and Intensive Care, Sestre milosrdnice University Hospital Center, Zagreb, Croatia. Retrospective data were collected from September 2009 to March 2013. All patients that developed VAP during the study period were eligible for the study. According to study results, the incidence of VAP was 29.4%. The most commonly isolated bacterium was Staphylococcus aureus (21.1%), followed by Pseudomonas aeruginosa (19.0%) and Acinetobacter species (13.6%). All Staphylococcus aureus isolates were susceptible to vancomycin and linezolid. Pseudomonas aeruginosa showed 100% susceptibility to cefepime and very high susceptibility to piperacillin-tazobactam (96%), ceftazidime (93%) and ciprofloxacin (89%). Ampicillin-sulbactam was highly effective for Acinetobacter species, showing resistance in only 8% of isolates. In conclusion, according to study data, appropriate empiric antibiotic therapy for patients with VAP without risk factors for multidrug-resistant bacteria is ceftriaxone and for patients with risk factors for multidrug-resistant bacteria ampicillin-sulbactam plus cefepime plus vancomycin or linezolid.Ventilacijska pneumonija (VAP) je vrlo česta u jedinicama intenzivnog liječenja, ali još uvijek postoje mnoge nedoumice vezane uz VAP, osobito što se tiče početnog empirijskog odabira antibiotika za liječenja VAP-a. Učestalost pojedinih patogena s različitom osjetljivošću na antibiotike razlikuje se od bolnice do bolnice. To je razlog zbog kojeg bi se empirijska antibiotska terapija trebala temeljiti ne samo na općim smjernicama (koje preporučuju terapiju na temelju prisutnosti rizičnih čimbenika za bakterije rezistentne na više lijekova), nego i na podacima o lokalnoj epidemiologiji. Cilj ovoga istraživanja je bio utvrditi mikrobiološki profil patogena koji uzrokuju VAP i njihovu osjetljivost na antibiotike. Istraživanje je provedeno u 15-krevetnoj Jedinici intenzivnog liječenja Odjela za anesteziologiju, reanimatologiju i intenzivno liječenje Kliničkog bolničkog centra “Sestre milosrdnice”, Zagreb, Hrvatska. Podaci su skupljani retrospektivno od rujna 2009. do ožujka 2013. godine. Svi bolesnici kod kojih se razvila VAP tijekom navedenog razdoblja su uključeni u istraživanje. Prema našim rezultatima, incidencija VAP-a bila je 29,4%. Najčešće izolirana bakterija je bila Staphylococcus aureus (21,1%), iza koje slijede Pseudomonas aeruginosa (19,0%) i Acinetobacter sp. (13,6%). Svi izolati bakterije Staphylococcus aureus su bili osjetljivi na vankomicin i linezolid. Pseudomonas aeruginosa je u 100% izolata bio osjetljiv na cefepim te visoko osjetljiv na piperacilin-tazobaktam (96%), ceftazidim (93%) i ciprofloksacin (89%). Ampicilin-sulbaktam se pokazao vrlo učinkovitim za Acinetobacter sp. s rezistencijom u samo 8% izolata. U zaključku, prema našim rezultatima, empirijska antibiotska terapija za bolesnike s VAP-om bez rizika za bakterije rezistentne na više lijekova je ceftriakson, a za bolesnike s rizičnim čimbenicima za bakterije rezistentne na više lijekova je ampicilin-sulbaktam plus cefepim plus vankomicin ili linezolid

Wine cultivars of grape vine in Herzegovina

Prema povijesnim podatcima vinova loza se na području Hercegovine uzgajala i u vrijeme starih Ilira, odnosno plemena Daorsa. Danas se prema procjenama u BiH nalazi oko 4.000 hektara pod vinovom lozom. U mnoštvu vinskih kultivara lokalnog sortimenta svojom kakvoćom izdvojili su se kultivari Žilavka i Blatina. Uz Žilavku se u hercegovačkim nasadima vinove loze uzgajaju prateće sorte Bena, Krkošija i Dobrogostina, a uz Blatinu autohtoni kultivar Trnjak, kao i poznati svjetski kultivari Vranac, Merlot i Alicante Bouschet. U razdoblju nakon Domovinskog rata na području Hercegovine podižu se i nasadi vinove loze u kojima su zastupljeni i ostali, cijenjeni kultivari kao što su Syrah, Chardonnay, Cabernet sauvignon, Souvignon blanc, Muscat ottonel, Graševina i brojni drugi.According to historical data of grape vine, it was cultivated also at the time of the ancient Illyrians and tribe of Daorsa. Nowadays, according to estimations in Bosnia and Herzegovina there are about 4,000 hectares cultivated with grape vine. In a multitude vine grape cultivars of local variety, Zilavka and Blatina stand out with their quality. With Zilavka in the Herzegovinian plantations of grape vine followed varieties Bena, Krkosija, Dobrogostina are cultivated and with Blatina autochthonous cultivar Trnjak, as well as a world well-known varieties Vranac, Merlot and Alicante Bouschet. In the period after the War for Independance in the territory of Herzegovina plantations of grape vine in which there are present other appreciate cultivars such as Chardonnay, Cabernet savignon, Souvignon blank, Nuscat ottonel, Grasevina and many others have been raise

Contribution of Presepsin, Procalcitonin and C-reactive protein to the SOFA Score in Early Sepsis Diagnosis in Emergency Abdominal Surgical Patients

Purpose: This study examined whether the addition of biomarkers presepsin (PSEP), procalcitonin (PCT) and C-reactive protein (CRP) to the initial SOFA (iSOFA) score can improve diagnostic accuracy of early sepsis diagnosis in emergency abdominal surgery patients. Materials and Methods: Seventy-two study subjects had diagnosis of acute abdomen due to gastrointestinal disturbances. The study evaluated diagnostic accuracy and predictive value of two models (iSOFA only and iSOFA combined with three biomarkers) for sepsis diagnosis. Results: The AUC value for the iSOFA was highest, followed by the AUC value obtained for PSEP, PCT and CRP (0.989, 0.738, 0.694 and 0.606, respectively).The logistic regression analysis of the two models showed for the first model that patients with a higher iSOFA score are almost two times more likely to suffer from sepsis. In the second model, patients with a higher iSOFA score and a higher level of biomarkers are three times more likely to have sepsis. Conclusions: Although the SOFA score is known to be the best diagnostic tool for sepsis diagnosis, it seems that among the three investigated markers PSEP and PCT– although not contributing to the iSOFA score– are good independent markers with significantly higher levels in septic than in non-septic patients. PSEP has the highest diagnostic accuracy for sepsis. Only the conventional marker CRP provides certain added value to the iSOFA score for sepsis prediction. Further investigations should be performed to study the possible diagnostic value of dynamic changes of the three examined markers in prediction and early diagnosis of sepsis

Extravascular lung water index as an indicator of lung injury in septic patients

Introduction. Transpulmonary thermodilution using PiCCO (Pulse-induced Contour Cardiac Output) is a standard minimally invasive method used for haemodynamic monitoring. Objectives. The goal of this paper is to examine the correlation and dynamics of the ExtraVascular Lung Water Index (EVLWI) as an indicator of acute lung injury in septic patients who underwent major abdominal surgery. Two groups of patients were selected: the ones with ALI (Acute Lung Injury): ALI patient group, and the ones without ALI: non-ALI patient group. A correlation between EVLWI and other haemodynamic and respiratory data in both groups were analyzed. Materials and methods. The study included 48 patients. Throughout the seven-day period EVLWI, GEDVI (Global End-Diastolic Volume Index), ITBVI (IntraThoracic Blood Volume Index), CI (Cardiac Index), SVRI (Systemic Vascular Resistance Index) were measured in both groups using PiCCO monitoring over 8-hour intervals as well as heart rate, mean arterial pressure, serum albumin concentration, PaCO2 (arterial partial pressure of carbon dioxide), PaO2 (arterial partial pressure of oxygen), PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio, lung compliance, lung resistance and ScvO2 (central venous oxygen saturation). All patients were analgosedated, intubated, mechanically ventilated, in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and Sequential Organ Failure Assessment (SOFA) scores calculated. Ventilator settings and dosage of vasoactive drugs were kept constant during the study. Results. EVLWI was significantly higher in ALI patients group compared to non-ALI patients group. In patients with ALI group 11/22 patients died (50%), in the non-ALI patients group 6/26 patients died (23%). EVLWI was significantly higher in patients that died compared to ones who survived. Conclusion. EVLWI is a good indicator of early acute lung injury in surgical patients with sepsis