DIAGNOSIS OF PERIOPERATIVE ANAPHYLAXIS

Every agent used during the perioperative period may be involved and have the potential to trigger both allergic, IgE and non– IgE reaction as well as non-specific (non-allergic) reactions. In many cases, an allergic mechanism cannot be ruled out and systematic investigations should be tested of all drugs and agents the patient was exposed to prior to the reaction. The complexity of agents used for anaesthesia and surgery present challenges when attempting to identify the culprit drugs and select proper testing to better recognition of trigger. The diagnosis of preoperative anaphylactic or anaphylactoid reaction is clinical and based upon the presence of characteristic symptom and signs that begin suddenly and developed rapidly in most cases. Elevations of mast cell mediators such as tryptase and histamine in the blood can help to distinguish anaphylaxis from other disorders that present with similar clinical picture. The secondary investigations of adverse perioperative drug reactions are highly specialised and include skin testing, in vitro testing and in some cases challenge tests. Any suspected reaction during anaesthesia must be extensively investigated and these diagnostic tests should be done in specialised centres. The cooperation between anaesthesiologists and allergists is necessary to provide the necessary diagnostic tests to identify the responsible drug, to carry out prevention and to provide recommendations for future anesthetic procedures

BOUGIE-ASSISTED INTUBATION – A BRIEF OVERVIEW ON TECHNIQUE AND CLINICAL SCENARIOS

Gumena elastična bužija, tj. Eschmannov uvodnik za endotrahealni tubus, je jednostavna i cijenom svima pristupačna naprava koja se može koristiti prigodom otežane intubacije. Bužija služi kao uvodnica za endotrahealni tubus. Pregledom dostupne literature moguće je pronaći niz članaka u kojima se opisuje uspješna upotreba bužije za zbrinjavanje otežanog dišnog puta te općenito zbrinjavanje dišnog puta u hitnim stanjima. Ovaj članak donosi kratak osvrt na tehniku korištenja plastične bužije te na kliničke scenarije u kojima upotreba bužije može dati značajan doprinos kod otežane endotrahealne intubacije.Gum elastic bougie, also known as Echmann tracheal tube introducer, is a simple device with affordable price to everyone, which can be used during diffi cult intubation. Bougie serves as an introducer for endotracheal tube. In the available literature, it is possible to fi nd a variety of articles that describe successful usage of bougie during diffi cult airway management and airway management in emergency. This article provides a brief overview on the technique of using bougie and on clinical scenarios in which the usage of bougie can signifi cantly contribute to the management of diffi cult intubation

REPLACEMENT OF VITAMIN-K DEPENDENT CLOTTING FACTORS IN A PATIENT WITH RETRANSPLANTED LIVER: PRO ET CONTRA

Kronična dekompenzacija terminalne bolesti jetre (engl. end stage liver disease, ESLD) udružena je sa složenim promjenama koagulacijskog sustava. U stabilnoj fazi jetrene bolesti taj sustav je ‘’rebalansiran’’, a karakterizira ga smanjenje kako antikoagulantnih tako i prokoagulantnih faktora zgrušavanja. Razni stresni čimbenici tijekom samog zahvata transplantacije (krvarenje, hemodinamska nestabilnost, oštećenje tkiva, obilna volumna nadoknada krvnim derivatima) mogu vrlo lako poremetiti rebalansirani koagulacijski sustav i rezultirati krajnje nepoželjnim ishodom, krvarenjem ili trombozom. Suvremeni pristup zbrinjavanju krvarenja kod transplantacije jetre podrazumijeva ciljane terapijske intervencije (korištenje koncentrata fi brinogena i koncentrata protrombiskog kompleksa (engl. prothrombin complex concentrate, PCC)) uz pomoć viskoelastičnih dinamičnih testova koagulacije poput rotacijske tromboelastometrije (ROTEM). Brojna istraživanja pokazala su da takav pristup smanjuje potrebu za primjenom krvnih pripravaka u perioperacijskom razdoblju. U ovom radu prikazana je četrdesetogodišnja bolesnica s preegzistirajućom parcijalnom trombozom gornje mezenteričke vene i preboljelom plućnom embolijom, koja je zbog relapsa autoimunog hepatitisa podvrgnuta retransplantaciji jetre. Masivno krvarenje tijekom zahvata retransplantacije jetre zahtijevalo je masivnu transfuziju uz upotrebu PCC-a intraoperacijski sa ciljem postizanja hemostaze. Bolesnica je šesti poslijeoperacijski dan razvila trombozu presatka i vene porte i bila podvrgnuta ponovnoj retransplantaciji. Potrebna su dodatna istraživanja koja će utvrditi učinkovitost postizanja hemostaze primjenom PCC-a kao i procjenu njegove perioperacijske trombogenosti.End-stage liver disease is associated with complex haemostatic system changes. In the course of stable liver disease, this system is ‘rebalanced’ and characterized by reduction in both anticoagulant and procoagulant coagulation factors. During liver transplantation, the rebalanced coagulation system can easily be disrupted by various stress factors (bleeding, hemodynamic instability, tissue damage, large volume resuscitation with blood products) and result in extremely undesirable outcome, bleeding or thrombosis. Current approach in the management of bleeding during liver transplantation involves goaldirected therapy (administration of fi brinogen concentrate and prothrombin complex concentrate (PCC)) guided by dynamic viscoelactic tests of coagulation, e.g., rotational thromboelastometry (ROTEM). Numerous studies have demonstrated reduced perioperative transfusion requirements with such an approach. Hereby, we present a case of a 40-year-old female patient with preexisting partial superior mesenteric vein thrombosis and history of pulmonary embolism, who underwent liver re-transplantation due to relapse of autoimmune hepatitis. Massive bleeding during liver re-transplantation required assive transfusion with the use of PCC intraoperatively to achieve hemostasis. The patient developed graft and portal vein thrombosis on postoperative day 6 and required re-transplantation. Additional studies are needed to determine the effi cacy of PCC application in achieving effective hemostasis and to evaluate its perioperative prothrombotic potential