Gastric tube ulcer perforating the pericardium after subtotal esophagectomy [Perforacija ulkusa želučanog supstituta u perikard nakon subtotalne ezofagektomije]

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature

EFFECT OF CUMULATIVE FLUID BALANCE DURING ICU STAY ON IN-HOSPITAL MORTALITY IN PATIENTS SURGICALLY TREATED FOR INFECTIVE ENDOCARDITIS

Infektivni endokarditis (IE) upalna je bolest endokarda uzrokovana mikroorganizmima koji formiraju vegetacije na srčanim zalicima ili septalnim defektima. Dijagnosticira se prema modifi ciranim kriterijima Duke od kojih su najvažniji ehokardiografski vegetacija na površini endokarda i pozitivne hemokulture na najčešće uzročnike IE. Liječi se konzervativno i kirurški. Kod bolesnika kirurški liječenih zbog IE često je prisutna poslijeoperacijska hemodinamska nestabilnost uzrokovana hipovolemijom, slabosti srca multifaktorske etiopatogeneze i poremećajima tonusa periferne vaskulature. Korigira se nadoknadom volumena i korištenjem vazoaktivnih lijekova u perioperacijskom razdoblju. U ovom istraživanju ispitan je utjecaj kumulativne bilance unosa i gubitaka tekućine u jedinici intenzivne medicine (JIM) na unutarbolničku smrtnost, stopu provođenja bubrežnog nadomjesnog liječenja, trajanje mehaničke ventilacije, trajanje boravka u jedinici intenzivne medicine i parametre plućne funkcije u bolesnika operiranih zbog IE. Od 65 ispitanika koji su operirani zbog IE u kliničkoj ustanovi u razdoblju od 4 godine 55 bolesnika je preživjelo, a 10 umrlo (stopa smrtnosti od 15 %). Sedam (70 %) umrlih bolesnika imalo je kumulativnu bilancu tekućine veću od medijana (1190 mL). Binarnom logističkom regresijom, uzevši u obzir kovarijable zbroja SOFA i dobi bolesnika, dokazan je utjecaj kumulativne bilance na povećanje unutarbolničke smrtnosti (exp(B)=2,753, p=0,05). Nije dokazana statistički značajna razlika u kumulativnoj bilanci tekućine između bolesnika kojima je provođeno odnosno nije provođeno bubrežno nadomjesno liječenje, kao ni povezanost kumulativne bilance tekućine i trajanja mehaničke ventilacije, tj. boravka u JIM. Dokazana je statistički značajna povezanost trajanja mehaničke ventilacije i boravka u JIM (SpearmanIntroduction: Infective endocarditis (IE) is an infl ammatory disease of endocardium caused by bacteria or fungi. It is caused microbial adhesion to endocardial surface caused by the presence of bacteria or fungi in the bloodstream. Its clinical features are fever, malaise, heart murmurs, shortness of breath and symptoms caused by septic emboli. Current standard in the diagnosis of IE are Duke criteria, according to which two major (echocardiographic evidence and positive blood cultures for most common infective agents that cause IE), one major and three minor or fi ve minor (pre-existing cardiac conditions, fever, vascular phenomena, immunologic phenomena and positive blood cultures) criteria need to be present to confi rm the diagnosis of IE. It is treated with targeted antimicrobial therapy, and open-heart surgery using cardiopulmonary bypass is performed if there is persistent bacteremia, signifi cant hemodynamic instability or threat of septic embolization. Hemodynamic instability is common during postoperative period due to systemic infl ammatory response and myocardial injury after cardiopulmonary bypass and it is treated with volume replacement and vasoactive drugs. Aim: The aim of this study was to determine whether increased fl uid balance during intensive care unit (ICU) stay after IE surgery had an effect on in-hospital mortality, duration of mechanical ventilation and ICU stay, need for renal replacement therapy and postoperative lung function. Sixty-fi ve patients operated for native valve IE and treated in ICU specialized for cardiac patients in a tertiary hospital were included in this observational study. Design of the study was approved by the institutional ethics committee. Patients with pre-existing lung disease, history of malignant disease in the last 5 years, or history of organ transplantation were excluded. Demographic data (age and gender), clinical variables needed to calculate SOFA (sepsis related organ failure assessment) score, ventilator settings, fl uid gains and losses during ICU stay, duration of mechanical ventilation and ICU stay, PaO2/FiO2 ratio at ICU admission and at 3, 6, 12 and 24 h post-admission, and in-hospital mortality data were collected. There were 55 (85%) male and ten (15%) female patients, mean age 54.2±15 years. Median fl uid gain/loss balance was +1190 mL (IQR -120 mL - +3090 mL), median duration of mechanical ventilation was 17 h (IQR 13.5-22.5 h) and median duration of ICU stay was 60 h (IQR 42-82 h). Ten (15%) patients died during hospital stay. Non-survivors had a signifi cantly higher proportion of fl uid balance above median (70% vs. 30%) compared to survivors (56% vs. 44%) (p=0.05, age and SOFA score adjusted binomial logistic regression with post-hoc Bonferroni correction). Correlation was found between duration of mechanical ventilation and ICU stay (Spearman’

Mogućnost procjene odgovora na nadoknadu tekućine pomoću interakcija pluća-srce uzrokovanima promjenama pozitivnog tlaka na kraju ekspirija

Goal: Various monitoring methods have been used throughout history to discriminate between volume responsive and volume non-responsive patients: static parameters, dynamic parameters, and maneuver provoked parameters (positive end expiratory pressure (PEEP) induced central venous pressure (CVP) change and passive leg raise (PLR) induced stroke volume index (SVI) change). Goal of this study is to assess whether PEEP induced lung-heart interactions may be used to reliably assess volume responsiveness in mechanically ventilated patients after major abdominal surgery. Methods: 50 sedated and relaxed mechanically ventilated patients with 5 mbar of PEEP admitted to a mixed surgical ICU were measured mean arterial pressure (MAP), heart rate (HR), CVP, cardiac index (CI), stroke volume index (SVI) and pulse pressure variation (PPV) at 5 timepoints – baseline, 3 minutes at PEEP of 15 mbar, after return of PEEP to 5 mbar, while performing PLR maneuver of 3-minute duration and after return to supine position. Receiver operator characteristic (ROC) curves were used to assess predictive ability of measured parameters to assess volume responsiveness defined as PLR induced SVI increase ≥ 7%. Results: Volume responsive patients had lower baseline CVP and SVI, and higher PPV. Both responders and non- responders had a staistically significant PEEP induced drop in SVI and MAP, with an increase of PPV and CVP. During PLR, both groups demonstrated a significant increase in MAP and CVP and decrease in PPV, but only volume responders had a significant increase of CI and SVI and heart rate decrease. ROC curves were used to assess predictive ability of parameters to assess volume responsiveness, and only PPV at 5 mbar PEEP (AUC=0.88), PPV at 15 mbar PEEP (AUC=0.83) and PLR induced HR drop (AUC=0.83) may be considered reliable in clinical practice. Conclusions: PEEP induced hemodynamic changes do not predict volume responsiveness reliably in comparison to PPV or PLR induced HR drop. Further studies are needed in hemodynamically unstable or patients with ARDS.Cilj: Kroz povijest su korišteni različite metode procjena odogovora na ekspanziju intravaskularnog volumena: statički parametri, dinamički parametri te parametri provocirani manevrima kao što su porast porast središnjeg venskog tlaka (CVP) uzrokovan povećanjem pozitivnog tlaka na kraju ekspirija (PEEP) ili porast indeksa udarnog volumena srca (SVI) uzrokovan pasivnim odizanjem nogu (PLR). Cilj ovog istraživanja je procijeniti da li je porast CVP uzrokovan povećanjem PEEP pouzdan prediktor odgovora na nadoknadu volumena nakon velikih abdominalno kirurških zahvata. Metode: 50 sediranih i miorelaksiranih mehanički ventiliranih bolesnika primljenih u jedinicu intenzivne medicine nakon elektivnog abdominalno kirurškog zahvata izmjeren je srednji arterijski tlak (MAP), frekvencija srca (HR), CVP, SVI i varijacija pulsnog tlaka (PPV) u 5 vremenskih intervala: početni, nakon 3 minute povećanja PEEP sa 5 na 15 mbar, nakon spuštanja PEEP na 5 mbar, nakon 3 minute PLR i nakon povratka nogu u vodoravan položaj. Porast SVI ≥ 7% smatra se pozitivnim odgovorom na volumnu ekspanziju, a osjetljivost i specifičnost parametara procijenjena je ROC krivuljama. Rezultati: Volumno responzivni bolesnici imali su niži početni CVP i SVI i viši PPV. Obje skupine imale su statistički značajan pad SVI i MAP nakon povećanja PEEP, sa porastom PPV i CVP. Tijekom PLR obje skupine imale su značajan porast MAP i CVP i pad PPV, ali samo responzivni pacijenti imali su značajan porast SVI i indeksa srca (CI). Nakon provedene analize ROC krivulja Samo PPV pri 5 mbar PEEP (AUC=0.88), PPV na 15 mbar PEEP (AUC=0.83) i PLR uzrokovan pad HR (AUC=0.83) mogu se smatrati pouzdanim u kliničkoj praksi. Zaključci: Hemodinamske promjene uzrokovane porastom PEEP ne mogu se smatrati pouzdanima u procjeni volumnog statusa bolesnika u odnosu na PPV ili PLR induciran pad frekvencije srca. Daljna istraživanja potrebna su na nestabilnim bolesnicima ili bolesnicima sa ARDS

Povezanost upalnih parametara i infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama kod COVID-19 pozitivnih bolesnika liječenih u jedinici intenzivnog liječenja – retrospektivna studija jednog centra

Objectives: During the COVID-19 pandemics we have seen in critically ill COVID-19 patients treated in the intensive care unit the parallel outbreak of multidrug resistant Gram-negative bacteria bloodstream infections, mainly Acinetobacter baumannii and Klebsiella pneumoniae. Methods: We conducted a retrospective cohort single-center study. The aim was to investigate the incidence, etiology and impact of intensive care unit bloodstream infections in COVID-19 patients admitted to the COVID-19 intensive care unit with a known burden of multidrug resistance and to evaluate the possibility that inflammatory parameters levels measured at two different time points of treatment can early predict multidrug resistant Gram-negative bacteria bloodstream infections and enable timely beginning of bacterial targeted antimicrobial therapy. Results: Our study confirmed that procalcitonin values of 2,46 mcg/L and neutrophil/lymphocyte ratio of 28,9 could be a reliable indicators for high risk stratification of multidrug resistant Gram-negative bacterial infection origin in critically ill COVID-19 patients (Mann Whitney U test, P=0,02). Conclusion: Monitoring dynamic shift of inflammatory parameters in critically ill COVID-19 patients could reliably help clinician to recognize the multidrug resistant Gram-negative bacteria bloodstream infections and start with the antimicrobial therapy in a timely manner.Cilj istraživanja: Tijekom COVID-19 pandemije uočili smo kod kritično bolesnih COVID-19 pozitivnih bolesnika liječenih na odjelu intenzivne njege paralelno izbijanje infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama, uglavnom Acinetobacter baumannii i Klebsiella pneumoniae. U praksi rezultati mikrobiološke potvrde infekcija krvi završeni su s određenom vremenskom odgodom. Stoga primarni cilj istraživanja bio je odrediti povezanost upalnih parametara (leukociti, limfociti, neutrofili, omjer neutrofila i limfocita, C-reaktivni protein, prokalcitonin) mjerenih u dvije različite vremenske točke (dan prijema u jedinicu intenzivnog liječenja i dan nastanka infekcija krvi potvrđenih pozitivnim hemokulturama) i nastanka infekcija krvi uzrokovanih multirezistentnim Gram negativnim. Sekundarni ciljevi istraživanja bili su istražiti učestalost, etiologiju i utjecaj infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama na ishod liječenja COVID-19 pozitivnih bolesnika. Materijali i metode: Proveli smo retrospektivno kohortno istraživanje u Kliničkoj bolnici Dubrava na intenzivističkom odjelu COVID-19 pozitivnih bolesnika u vremenskom period od 31. listopada 2020. godine do 31. ožujka 2021. godine. U istraživanju je sudjelovalo 166 COVID-19 pozitivnih bolesnika koji su zadovoljili kriterije uključenja u istraživanje. 122 COVID-19 bolesnika imali su mikrobiološki potvrđenu infekciju krvi uzrokovanu multirezistentnim Gram negativnim bakterijama. Kontrolna gupa imala je 44 COVID-19 bolesnika koji nisu razvili infekciju krvi. Svi podaci bolesnika skupljali su se iz povijesti bolesti i elektroničke baze podataka. Rezultati: Naša studija potvrdila je cut-off vrijednosti upalnih parametara prokalcitonina od 2,46 mcg/L i omjer neutrofila/limfocita od 28,9 kao pouzdane pokazatelje stratifikacije visoko rizičnih COVID-19 bolesnika za nastanak infekcije krvi uzrokovane multirezistentnim Gram negativnim bakterijama, Acinetobacter baumannii i Klebsiella pneumoniae (Mann Whitney U test, P=0,02). Zaključak: Dinamički monitoring upalnih parametara sa cut-off vrijednostima proklacitonina i omjera neutrofila i limfocita u različitim vremenskim intervalima u kritično bolesnih COVID-19 pozitivnih bolesnika pouzdani je pokazatelj visokog rizika nastanka infekcija krvi uzrokovanih multirezistentnim Gram negativnim bakterijama koji u kliničkoj praksi omogućuje pravovremeno uvođenje ciljane antimikrobne terapije prije dospijeća mikrobiološke potvrde

Gastric Tube Ulcer Perforating the Pericardium after Subtotal Esophagectomy

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal.We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature

Perforacija ulkusa želučanog supstituta u perikard nakon subtotalne ezofagektomije

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature.Prikazan je slučaj 62 godišnjeg muškarca kod kojega je zbog karcinoma proksimalne trećine jednjaka učinjena subtotalna ezofagektomija. Godinu i pol dana nakon operacije javila se nagla bol u epigastriju koja je nastala kao posljedica perforacije ulkusa želučanog supstituta u perikard

Inflammatory Biomarkers Affecting Survival Prognosis in Patients Receiving Veno-Venous ECMO for Severe COVID-19 Pneumonia

Severe COVID-19 pneumonia in which mechanical ventilation is unable to achieve adequate gas exchange can be treated with veno-venous ECMO, eliminating the need for aggressive mechanical ventilation which might promote ventilator-induced lung injury and increase mortality. In this retrospective observational study, 18 critically ill COVID-19 patients who were treated using V-V ECMO during an 11-month period in a tertiary COVID-19 hospital were analyzed. Biomarkers of inflammation and clinical features were compared between survivors and non-survivors. Survival rates were compared between patients receiving ECMO and propensity matched mechanically ventilated controls. There were 7 survivors and 11 non-survivors. The survivors were significantly younger, with a higher proportion of females, higher serum procalcitonin at ICU admission, and before initiation of ECMO they had significantly lower Murray scores, PaCO2, WBC counts, serum ferritin levels, and higher glomerular filtration rates. No significant difference in mortality was found between patients treated with ECMO compared to patients treated using conventional lung protective ventilation. Hypercapnia, leukocytosis, reduced glomerular filtration rate, and increased serum ferritin levels prior to initiation of V-V ECMO in patients with severe COVID-19 pneumonia may be early warning signs of reduced chance of survival. Further multicentric studies are needed to confirm these findings