Upravljanje antibioticima vođeno prokalcitoninom: konsenzus eksperata iz balkanskih zemalja

Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program.Sepsa kao posljedica infekcije jedan je od čestih uzroka smrti među kritično oboljelim pacijentima. Najčešća mjesta infekcije su donji respiracijski putovi, abdomen, mokraćni sustav i infekcije krvi povezane s centralnim vesnkim kateterima. Rana empirijska upotreba antibiotika širokog spektra kod onih s teškom sepsom/septičnim šokom radi smanjivanja smrtnosti može voditi prekomjernoj upotrebi antibiotika, bakterijskoj rezistenciji i povećanju troškova. Među mnogobrojnim serumskim biološkim biljezima prokalcitonin se pokazao kao jedan od najpouzdanijih u dijagnosticiranju sepse. Jedan od bitnih načina za smanjenje bakterijske rezistencije predstavlja uvođenje protokola o upotrebi antibiotika, naročito među kritično oboljelima u jedinicama intezivnog liječenja gdje su prisutni multirezistentni patogeni. Prokalcitoninom vođeni protokoli za upotrebu antibiotika prvo su uvedeni u Zapadnoj Europi i Azijsko-pacifičkim zemljama, kao i u Americi. S obzirom na to da se ovakav program pokazao učinkovitim u pogledu potrošnje antibiotika, a ujedno i u poboljšanju ishoda liječenja, grupa eksperata s Balkana odlučila je napraviti svoje vlastite preporuke. Tijekom izrade ovog protokola za uvođenje i dužinu trajanja antibiotskog liječenja autori su se uglavnom usredotočili na pretragu literature koja se tiče donjeg respiracijskog sustava i sepse. Protokol uključuje težinu bolesti, kliničku procjenu i razine prokalcitonina. Razvijanje konsenzusa o kliničkom algoritmu od strane eminentnih stručnjaka iz različitih područja medicine trebalo bi omogućiti kliničarima da prokalcitonin koriste pri donošenju odluke o započinjanju i ranijem prestanku terapije antibioticima. Neophodno je da prokalcitoninom vođen algoritam postane sastavni dio institucionalnog protokola o upotrebi antibiotika

Prediction value of oxygenation index as predictor for postoperative pulmonary complications in urologic surgery

Introduction: It is believed that pressure/flow (P/F) ratio (arterial oxygen to inspired oxygen fraction) Does not give the best expression of oxygenation status in mechanically ventilated patients. Therefore, a new oxygenation index (OI) where the mean airway pressure (MAP) is incorporated (PaO2/FiOxMAP) Is showed as superior to P/F in expression of the lung oxygenation status. In this article we wanted to assess the prediction value of OI calculated during urological surgeries as a predictive marker for Developing postoperative pulmonary complications (PPC). Material and methods: We evaluated all elective urologic patients operated in general endotracheal anesthesia, aged 18 to 65 years, without any known history of respiratory disease for the period from January till December 2017. We calculated the P/F ratio and the OI at three time points: after induction in general endotracheal anesthesia in the beginning of mechanical ventilation, 1 hour after induction in Anesthesia, and at the end of the surgery before weaning the mechanical ventilation. The primary Outcomes were PPC defined by European Society of Anesthesia. The second outcomes were: length of Hospital stay, admission to intensive care unit (ICU) and mortality. Results: A total of 240 patients who met the inclusion criteria were included in this evaluation and finally analyzed. PPC was diagnosed in 25% of patients and respectively 75% were without Complications. The postoperative hospital stay was longer in PPC group no matter they were operated laparoscopically or with classic open surgery (PPC laparoscopy 4.9 ± 2.2 vs. non PPC laparoscopy 3.3 ± 1.7, PPC laparotomy 6.8 ± 5.2 vs. non PPC 5.6 ± 2.1 laparotomy). Ten patients were admitted to ICU, 8 from PPC group and 2 from non PPC group. In PPC group patients were admitted to ICU for mean 3.7 ± 2.4 days, and in non PPC group patients were hospitalized in ICU only for 2 days. All evaluated patients were discharged from the hospital and no mortality was observed in the 30 postoperative days. In the univariate and multivariate logistic regression analysis neither OI nor P/F were significantly associated with PPC. Conclusion: This study does not offer a conclusive answer to the prediction value of OI for PPC. It would be fruitful to pursue further research about predictive variables for pulmonary complications. Keywords: oxygenation index, pressure/flow ratio, mean airway pressure, postoperative pulmonary complications

Carboxyhemoglobin changes in relation to inspired oxygen fraction during general anesthesia

Measurement of carboxyhemoglobin could be a new method for evaluation of the severity of inflammatory airway disease, acute organ dysfunction, or stress by surgery and anesthesia. To use this measurement during mechanical ventilation, it is important to clarify the effects of factors that interfere with carboxy- hemoglobin levels. The aim of our study was to investigate the preoperative changes of carboxyhemoglobin to inspired oxygen fraction during general anesthesia and mechanical ventilation. Our second aim was to evaluate the effect of preoxygenation on the level of carboxyhemo- globin. Methods: The study included 30 patients scheduled for urologic surgery under general endotracheal anesthesia, aged 18-60 years, divided into two groups. The study group comprised patients who were smoking cigarettes or tobacco pipe, while the control group included non-smokers. In both groups carboxyhemoglobin levels were determined preoperatively, after preoxygenation, and one hour after induction in anesthesia. Results: carboxyhemoglobin levels were decreased after preoxygenation in both groups. One hour after induction in anesthesia under mechanical ventilation with inhaled fraction of a mixture of O2 (50%) and air (50%) the average values of carboxyhemoglobin between the two groups were different. The average values of carboxyhemoglobin between the two groups in all three time points were statistically significantly different (p=0.00). Conclusion: Changes in carboxyhemoglobin concentrations in arterial blood occur during general anesthesia and mechanical ventilation, although these amplitudes are small when compared to carbon monoxide intoxication. It is likely that organ perfusion and functions are affected by these monoxide gas mediators during surgery

Procalcitonin Guided Antibiotic Stewardship: A Balkan Expert Consensus Statement

Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Purpose: Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery. Methods: We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) < 60 ml/min/1.73 m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72 h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD. Results: We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7 days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7 days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P < 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P < 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%. Conclusion: One in ten major surgery patients developed AKD beyond 7 days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors