Koagulopatija kod traumatske ozljede mozga

Traumatic brain injury associated coagulopathy is a widely recognized risk factor for secondary brain damage and a powerful predictor related to outcome and prognosis. It is estimated that two thirds of patients with severe TBI will develop a coagulopathy. Pathophysiological pathway of TBI associated coagulopathy remains poorly defined. It includes combination of hypercoagulable and hypofibrinolytic states that result in persistent and delayed intracranial haemorrhage and systemic bleeding. The proposed mechanisms include release of tissue factor, hyperfibrinolysis, disseminated intravascular coagulopathy, platelet disfunction and protein C activation. The goal of this review is to summarize the current knowledge regarding the mechanisms of traumatic brain injury associated coagulopathy and treatment options.67Koagulopatije kod traumatske ozljede mozga bitan su faktor u razvoju sekundarnih ozljeda mozga i snažan su prediktor za ishod i prognozu liječenja. Procijenjuje se da dvije trećine pacijenata sa teškom traumom mozga razvije koagulopatiju. Patofiziološki mehanizam koagulopatije kod traumatske ozljede mozga je slabo razjašnjen. Uključuje otpuštanje tkivnog faktora, hiperfibrinolizu, diseminiranu intravaskularnu koagulopatiju, poremećaj funkcije trombocita i aktivaciju proteina C. Cilj ovoga rada je osvrnuti se na aktualna saznanja o patofiziologiji koagulopatije kod traumatske ozljede mozga i metode liječenja

COVID-19 and Mechanical Ventilation

U kliničkoj slici COVID-19 bolesti, akutna hipoksemijska respiracijska insuficijencija najčešći je razlog prijema u jedinicu intenzivne medicine. U bolesnika koji razviju takvo zatajenje, odabir respiratorne potpore ovisi o promjenama u popustljivosti respiratornog sustava te se razlikuju dva oblika zatajenja – zatajenje s očuvanom i narušenom respiratornom mehanikom. Kod bolesnika kojima je respiratorna mehanika očuvana, uzrok hipoksemije je u poremećenim mehanizmima autoregulacije plućne vaskulature te je terapija izbora učestalo postavljanje bolesnika u potrbušni položaj uz terapiju visokim protokom kisika na nosnu kanilu (HFNO) ili korištenje neinvazivne ventilacije. Kada je u COVID-19 prisutan sindrom akutnoga respiracijskog distresa (ARDS) u klasičnom smislu riječi, principi liječenja jednaki su kao i u ARDS-u u drugim virusnim pneumonijama – endotrahealna intubacija i mehanička ventilacija s korištenjem pozitivnog tlaka na kraju ekspirija (PEEP) koji je podešen na dovoljno visoku razinu da bi se izbjeglo cikličko otvaranje i zatvaranje alveola ovisno o fazi respiratornog ciklusa. Preporučuje se restriktivan pristup udjelu kisika u inspiratornoj smjesi (FIO2) s vrijednostima odabranim da se saturacija kisikom u arterijskoj krvi održava oko 90 %. Tijekom mehaničke ventilacije preporučuje se sedacija bolesnika midazolamom ili deksmedetomidinom uz neuromišićnu relaksaciju u bolesnika koji imaju teži tijek bolesti. Korištenje adjuvantnih izvantjelesnih metoda kao što su ECMO ili ECCO koje su dokazano korisne kod liječenja ARDS-a drugih uzroka, pokazalo se nedovoljno učinkovitim u bolesnika oboljelih od COVID-19.Acute hypoxemic respiratory failure is the main clinical feature of COVID-19, and the most common reason for admission to the intensive care unit. In patients who develop such failure, the choice of respiratory support depends on the weakness of the respiratory system, with two forms of failure - preserved vs. failing respiratory mechanics. In patients with preserved respiratory mechanics, lung compliance is normal and hypoxemia is caused by loss of hypoxic pulmonary vasoconstriction. Prone positioning combined with high flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) is the therapy of choice in these patients. When acute respiratory distress syndrome (ARDS) is present with COVID-19, the therapeutic approach is similar as with other viral pneumonias – initiation of mechanical ventilation via endotracheal tube, positive end expiratory pressure (PEEP) set to levels in which cyclic opening and closure of alveoli is avoided, and fraction of inspired oxygen set to lowest possible levels needed to achieve arterial oxygen saturation of 90%. In order to avoid patient-ventilator dyssynchrony, use of sedatives (such as midazolam or dexmedetomidine) and neuromuscular relaxants are recommended. Extracorporeal support methods such as ECMO and ECCO, which are proven to be effective when treating ARDS caused by other sources, have not shown adequate efficacy in COVID-19 patients

Modaliteti regionalne analgezije u abdominalnoj kirurgiji i kirurgiji donjih ekstremiteta - usporedba i učinkovitosti

A significant component of all surgical procedures and postoperative treatment is pain management. Due to the physiological and psychological advantages of pain relief, it is one of the foremost indicators of quality of care. Today, there are various modalities of pain reduction, aimed to reduce patient discomfort and minimize side effects, which can be divided by therapeutic agents used (opioid or non-opioid), route of administration (intravenous, regional, oral, etc.) and modality (controlled by patients or “as needed”). Although opioids have proven to be very effective pain relief agents and are commonly used in postoperative analgesia, concerns about their side effects have spurred the development of modified, multimodal treatments that seek to minimize opioid use and associated drawbacks. Enhanced recovery protocols that emphasize sparing administration of opioids are growing in importance, andresulting in reduced length of hospital stay after abdominal and lower limb surgery. To further improve such protocols and optimize postoperative care for individual patient needs, it is imperative to fully assess the efficacy of available drugs and analgesia modalities.Zbrinjavanje boli predstavlja značajan dio svakog kirurškog zbrinjavanja i postoperativnog liječenja. Zbog tjelesnih i psiholoških benefita, učinkovita analgezija danas se smatra jednim od najvažnijih pokazatelja kvalitete zdravstvene skrbi. Postoji više modaliteta liječenja boli, s ciljem umanjivanja nelagode za pacijenta i minimiziranja neželjenih učinaka do kojih pritom može doći. Modalitete analgezije razlikujemo prema vrsti korištenog agensa (opioidni ili neopioidni), prema načinu primjene lijeka (intravenski, regionalno, peroralno, itd.) te jesu li kontrolirani od strane pacijenta ili se uzimaju po potrebi. Iako su opioidi dokazano vrlo učinkoviti, i najčešće korišteni lijekovi u terapiji poslijeoperacijske boli, ne jenjava zabrinutost zbog njihovih nuspojava. Posljedično, došlo je do razvoja modificiranih, multimodalnih načina liječenja, koji nastoje umanjiti ili izbjeći upotrebu opioida. Isto naglašavaju aktualne smjernice za ubrzani oporavak nakon operacije, koje se sve šire primjenjuju jer dokazano ubrzavaju oporavak i skraćuju ukupni boravak pacijenta u bolnici nakon operacija abdomena i donjih ekstremiteta. Neophodno je dobro procijeniti učinkovitost dostupnih lijekova i analgetskih modaliteta kako bi se protokoli i dalje unaprijeđivali, a postoperacijska skrb optimizirala i individualizirala

Kombinirana primjena terapije visokim protocima kisika i potrbušnog položaja kao alternativa intubaciji u COVID-19: prikaz slučaja i pregled literature

The use of high-flow nasal cannula (HFNC) in COVID-19 patients is a controversial topic due to the benefits and risks which may occur in patients and healthcare workers. The goal of this treatment modality is potential avoidance of invasive mechanical ventilation, but generation of aerosol and increased healthcare professional infection risk must be considered. We present a case of a SARS-CoV-2-positive 71-year-old male with acute hypoxemic respiratory failure, who was successfully treated with HFNC combined with prone positioning. Furthermore, we discuss recent literature concerning potential issues of HFNC treatment in COVID-19 patients.Terapija visokim protocima kisika u bolesnika oboljelih od COVID-19 kontroverzna je tema zbog koristi i rizika za bolesnike i zdravstvene djelatnike. Cilj ovog modaliteta liječenja je potencijalno izbjegavanje potrebe za endotrahealnom intubacijom i mehaničkom ventilacijom, ali zbog povećanog generiranja aerosola potrebno je uzeti u obzir povećan rizik za obolijevanje zdravstvenih djelatnika. Prikazujemo slučaj 71-godišnjaka oboljelog od infekcije SARS-CoV-2 s akutnim respiracijskim zatajenjem koji je uspješno liječen terapijom visokim protocima kisika u potrbušnom položaju. Uz prikaz slučaja daje se i kratak osvrt na noviju literaturu koja se bavi terapijom visokim protocima kisika u bolesnika s COVID-19

Hemodynamic optimization is sepsis: a path towards personalization

Sepsa je hemodinamski vrlo kompleksno stanje koje zahtjeva akutne dijagnostičke i terapijske postupke. Uporaba noradrenalina kao vazoaktivne potpore i glavnog supstrata za održavanje srednjeg arterijskog tlaka iznad 65 mmHg dobro je ustoličena klinička praksa, ali ne bez svojih limita. Uporaba sekundarnih vazoaktivnih lijekova poput vazopresina i sintetskog angiotenzina II, akutnije i vremenski definiranije liječenje sve više ulaze u jedinice intenzivne medicine. Praćenje progresije sepse, odnosno septičnog šoka, također biva unaprijeđeno, putem novijih modaliteta hemodinamskog monitoringa te novih point-of-care laboratorijskih nalaza koji točnije prate progresiju bolesti, na primjer promatranja dinamike renina. U ovom preglednom radu prikazane su novi modaliteti liječenja i personalizirani pristup pacijentu sa septičnim šokom te praćenja uspješnosti liječenja.Sepsis is a hemodynamically very complex condition that requires acute diagnostic and therapeutic procedures. The use of norepinephrine as vasoactive support and the main substrate for maintaining mean arterial pressure above 65 mmHg is a well-established clinical practice, but not without its limits. The use of secondary vasoactive drugs such as vasopressin and synthetic angiotensin II, and more acute and time-determining treatment are increasingly entering the intensive care units. Monitoring the progression of sepsis, or septic shock, is also being improved, through newer modalities of hemodynamic monitoring and new point-of-care laboratory findings that more closely monitor disease progression, for example by observing renin dynamics. In this review paper, new modalities of treatment and personalization of care for patients with septic shock and monitoring of treatment success are presented

COVID-19 and Mechanical Ventilation

U kliničkoj slici COVID-19 bolesti, akutna hipoksemijska respiracijska insuficijencija najčešći je razlog prijema u jedinicu intenzivne medicine. U bolesnika koji razviju takvo zatajenje, odabir respiratorne potpore ovisi o promjenama u popustljivosti respiratornog sustava te se razlikuju dva oblika zatajenja – zatajenje s očuvanom i narušenom respiratornom mehanikom. Kod bolesnika kojima je respiratorna mehanika očuvana, uzrok hipoksemije je u poremećenim mehanizmima autoregulacije plućne vaskulature te je terapija izbora učestalo postavljanje bolesnika u potrbušni položaj uz terapiju visokim protokom kisika na nosnu kanilu (HFNO) ili korištenje neinvazivne ventilacije. Kada je u COVID-19 prisutan sindrom akutnoga respiracijskog distresa (ARDS) u klasičnom smislu riječi, principi liječenja jednaki su kao i u ARDS-u u drugim virusnim pneumonijama – endotrahealna intubacija i mehanička ventilacija s korištenjem pozitivnog tlaka na kraju ekspirija (PEEP) koji je podešen na dovoljno visoku razinu da bi se izbjeglo cikličko otvaranje i zatvaranje alveola ovisno o fazi respiratornog ciklusa. Preporučuje se restriktivan pristup udjelu kisika u inspiratornoj smjesi (FIO2) s vrijednostima odabranim da se saturacija kisikom u arterijskoj krvi održava oko 90 %. Tijekom mehaničke ventilacije preporučuje se sedacija bolesnika midazolamom ili deksmedetomidinom uz neuromišićnu relaksaciju u bolesnika koji imaju teži tijek bolesti. Korištenje adjuvantnih izvantjelesnih metoda kao što su ECMO ili ECCO koje su dokazano korisne kod liječenja ARDS-a drugih uzroka, pokazalo se nedovoljno učinkovitim u bolesnika oboljelih od COVID-19.Acute hypoxemic respiratory failure is the main clinical feature of COVID-19, and the most common reason for admission to the intensive care unit. In patients who develop such failure, the choice of respiratory support depends on the weakness of the respiratory system, with two forms of failure - preserved vs. failing respiratory mechanics. In patients with preserved respiratory mechanics, lung compliance is normal and hypoxemia is caused by loss of hypoxic pulmonary vasoconstriction. Prone positioning combined with high flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) is the therapy of choice in these patients. When acute respiratory distress syndrome (ARDS) is present with COVID-19, the therapeutic approach is similar as with other viral pneumonias – initiation of mechanical ventilation via endotracheal tube, positive end expiratory pressure (PEEP) set to levels in which cyclic opening and closure of alveoli is avoided, and fraction of inspired oxygen set to lowest possible levels needed to achieve arterial oxygen saturation of 90%. In order to avoid patient-ventilator dyssynchrony, use of sedatives (such as midazolam or dexmedetomidine) and neuromuscular relaxants are recommended. Extracorporeal support methods such as ECMO and ECCO, which are proven to be effective when treating ARDS caused by other sources, have not shown adequate efficacy in COVID-19 patients

Perioperative optimization of fluid and coagulation status in polytrauma patients

Kompleksnost i raznovrsnost stanja politraume čini te bolesnike iznimno zahtjevnim za ispravno zbrinjavanje. Kompleksnost je uvjetovana pravovremenim inicijalnim zbrinjavanjem politraumatiziranih bolesnika, ali i točnošću zbrinjavanja istih, jer manjkavosti i u jednom i u drugom aspektu dovode do produženog liječenja i loših ishoda. Budući da je dokazano kako je mortalitet politraumatiziranih bolesnika veći zbog intraoperativnog metaboličkog zatajenja, nego zbog nedovršenosti kirurškog zbrinjavanja, inicijalni operativni zahvati imaju za cilj normalizirati fiziologiju pacijenta te onemogućiti stvaranje nove, patološke homeostaze, putem damage control operativnih zahvata. Pri tome je postoperativna skrb bolesnika u jedinicama intenzivne medicine od iznimne važnosti, a današnji pristupi individualizacije medicinske intervencije, ciljane terapije volumenom i korekcije poremećaja koagulacije mijenjaju ranije unificirane i poopćene postupke. Pri tome se pokazalo kako detaljno i precizno praćenje volumnog stanja i koagulacije pomoću viskoelastičnih testova može uvelike ubrzati i poboljšati zbrinjavanje bolesnika, kako intraoperativno za vrijeme prvog damage control zahvata, tako i u jedicinama intenzivne medicine nakon i u pripremi za definitive kirurške zahvate.The complexity and variety of polytrauma conditions make these patients extremely complex for proper care. Complexity is conditioned by the acuteness of treating polytraumatized patients, but also by the accuracy of their care, because deficiencies in both aspects lead to prolonged treatment and reduced success. Since it has been proven that the mortality of polytraumatized patients is higher due to intraoperative metabolic failure than due to the incompleteness of surgical care, the initial surgical procedures aim to normalize the patient’s physiology and prevent the creation of a new, pathological homeostasis, through damage control surgical procedures. Postoperative care of patients in intensive care units is extremely important, and today’s perspectives, individualization of medical care and targeting of volume therapy and correction of coagulation disorders are changing previously unified and generalized procedures. In doing so, it was shown that more detailed monitoring of the patient’s volume status and monitoring of the coagulation status using viscoelastic tests can greatly speed up and improve patient care, both intraoperatively during the first damage control procedure, and in intensive care units after and in preparation for definitive surgical procedures

Preoperative Clonidine or Levobupivacaine – Effect on Systemic Inflammatory Stress Response

With perioperative pain control it is possible to supervise immune system, release of inflammation mediators, and influence on treatment outcome. Use of analgetics before the pain stimulus (preventive analgesia) obstruct development of neuroplastic changes in central nervous system, and reduces pain. Investigation hypothesis was that preoperative epidural clonidine is more efficient in blockade of systemic inflammatory stress response comparing to levobupivacaine. Patients were allocated to three groups, according to preoperative epidural use of clonidine, levobupivacaine or saline (control group). Before operation, 1 h after the beginning, 1 h, 6 h, 12 h and 24 h after the operation following parameters were analyzed: interleukine-6, C-reactive protein and leukocyte count. There were no significant differences between groups in age, gender, body mass index and operation time. In preoperative clonidine group, we found significant reduction in interleukine-6 levels throughout investigation time, compared to preoperative levobupivacaine group and control group. Also, C-reactive protein was significantly lower at the end of investigation, compared to other two groups. Leukocyte count was lower, and within the normal range in all investigation times only in preoperative clonidine group. We demonstrated significant difference that support importance of clonidine central effect on pain pathways and systemic inflammatory blockade