Measurement of intracranial pressure

U odraslih, intrakranijski prostor je zaštićen lubanjom, rigidnom strukturom sa stalnim unutarnjim volumenom od 1400 do 1700 mL. U fiziološkim stanjima , dijelovi intrakranijskog prostora su ( po volumenima): moždani parenhim – 80%, CST – 10%, i krv 10%. Monro- Kellieva doktrina govori da porast jednog od ovih volumena uzrokuje smanjenje ostala dva. Intrakranijski tlak može biti povišen u TOM-u, akutnom ishemijskom moždanom udaru opskrbnog područja velike arterije, intrakranijskom krvarenju i difuznim moždanim poremećajima poput meningitisa, encefalitisa te akutnog zatajenja jetre. Povećani IKT je poznat i kao intrakranijska hipertenzija i definiran je kao IKT veći od 20 mm Hg. IKT je normalno manji kod djece nego u odraslih, a može biti i subatmosferski u novorođenčadi. Mora se naglasiti da IKT nije samo broj nego se moraju uzeti u obzir dugotrajno mjerenje odnosno izgled valova tlaka koji mogu ukazivati na određena patološka stanja. Mjerenje IKT-a može se vršiti invazivno i neinvazivno. Invazivna mjerenja mogu se vršiti na različitim anatomskim mjestima: intraventrikularno, intraparenhimski, epiduralno, subduralno i subarahnoidalno te sa različitim senzorima: tekućinom spojenih, mikroprijenosnika te pneumatskih. VDL se smatra zlatnim standardom zbog preciznosti mada su i senzori s mikroprijenosnikom gotovo jednako precizni. VDL ima isto prednost jer je ujedno i terapijska metoda dreniranja viška likvora koja uzrokuje porast IKT-a. Obje metode povezane su s komplikacijama poput krvarenja i infekcija. Nadalje, nulti pomak je problem povezan s određenim mikroprijenosnicima. Novije studije dovode u pitanje svrhovitost invazivnog mjerenja IKT-a. Pojavljuju se i novije metode telemetrijskog bežičnog mjerenja. Neinvazivne tehnike mjerenja su TCD, mjerenje pomaka bubnjića, ONSD, NIRS, mjerenje OT-a, te korištenje CT-a i MRI-a. Te tehnike nemaju komplikacije povezane s invazivnim pristupom ali nisu pokazale preciznost mjerenja dovoljno veliku kako bi se rutinski primjenjivale.In adults, the intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume of 1400 to 1700 mL. Under physiologic conditions, the intracranial contents include (by volume) : brain parenchyma — 80 percent, cerebrospinal fluid — 10 percent and blood — 10 percent. Monroe -Kellie doctrine states that the rise in one of those volumes will cause decrease in other two. Intracranial pressure (ICP) can be elevated in traumatic brain injury, large artery acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as meningitis, encephalitis, and acute hepatic failure. Raised ICP is also known as intracranial hypertension and is defined as a sustained ICP of greater than 20 mm Hg. ICP is normally lower in children than adults, and may be subatmospheric in newborns. It must be emphasized that ICP is not just a number but its long-time dynamic must also be taken into consideration because some specific shapes of pressure waves can indicate pathologic states. The measurement of ICP can be done using invasive and non- invasive methods.Invasive methods of ICP measuring can be undertaken in different intracranial anatomical locations: intraventricular, intraparenchymal, epidural, subdural, and subarachnoidal. Ventriculostomy is considered the gold standard in terms of accurate measurement of pressure, although microtransducers are generally just as accurate. Ventriculostomy has also an advantage of being therapeutic method as well because excess of cerebrospinal fluid causing the raise of ICP can be easily drained. Both invasive techniques are associated with a minor risk of complications such as hemorrhage and infection. Furthermore, zero drift is a problem with selected microtransducers. Newer studies have questioned the benefit of the invasive intracranal pressure measurement.New methods of telemetric wireless measurement techniques are also emerging. Non-invasive methods include transcranial Doppler, tympanic membrane displacement, optic nerve sheath diameter, ocular pressure, near - infrared spectroscopy, CT scan and MRI. Those techniques are without the invasive methods risk of complication, but fail to measure ICP accurately enough to be used as routine alternatives to invasive measurement

Measurement of intracranial pressure

U odraslih, intrakranijski prostor je zaštićen lubanjom, rigidnom strukturom sa stalnim unutarnjim volumenom od 1400 do 1700 mL. U fiziološkim stanjima , dijelovi intrakranijskog prostora su ( po volumenima): moždani parenhim – 80%, CST – 10%, i krv 10%. Monro- Kellieva doktrina govori da porast jednog od ovih volumena uzrokuje smanjenje ostala dva. Intrakranijski tlak može biti povišen u TOM-u, akutnom ishemijskom moždanom udaru opskrbnog područja velike arterije, intrakranijskom krvarenju i difuznim moždanim poremećajima poput meningitisa, encefalitisa te akutnog zatajenja jetre. Povećani IKT je poznat i kao intrakranijska hipertenzija i definiran je kao IKT veći od 20 mm Hg. IKT je normalno manji kod djece nego u odraslih, a može biti i subatmosferski u novorođenčadi. Mora se naglasiti da IKT nije samo broj nego se moraju uzeti u obzir dugotrajno mjerenje odnosno izgled valova tlaka koji mogu ukazivati na određena patološka stanja. Mjerenje IKT-a može se vršiti invazivno i neinvazivno. Invazivna mjerenja mogu se vršiti na različitim anatomskim mjestima: intraventrikularno, intraparenhimski, epiduralno, subduralno i subarahnoidalno te sa različitim senzorima: tekućinom spojenih, mikroprijenosnika te pneumatskih. VDL se smatra zlatnim standardom zbog preciznosti mada su i senzori s mikroprijenosnikom gotovo jednako precizni. VDL ima isto prednost jer je ujedno i terapijska metoda dreniranja viška likvora koja uzrokuje porast IKT-a. Obje metode povezane su s komplikacijama poput krvarenja i infekcija. Nadalje, nulti pomak je problem povezan s određenim mikroprijenosnicima. Novije studije dovode u pitanje svrhovitost invazivnog mjerenja IKT-a. Pojavljuju se i novije metode telemetrijskog bežičnog mjerenja. Neinvazivne tehnike mjerenja su TCD, mjerenje pomaka bubnjića, ONSD, NIRS, mjerenje OT-a, te korištenje CT-a i MRI-a. Te tehnike nemaju komplikacije povezane s invazivnim pristupom ali nisu pokazale preciznost mjerenja dovoljno veliku kako bi se rutinski primjenjivale.In adults, the intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume of 1400 to 1700 mL. Under physiologic conditions, the intracranial contents include (by volume) : brain parenchyma — 80 percent, cerebrospinal fluid — 10 percent and blood — 10 percent. Monroe -Kellie doctrine states that the rise in one of those volumes will cause decrease in other two. Intracranial pressure (ICP) can be elevated in traumatic brain injury, large artery acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as meningitis, encephalitis, and acute hepatic failure. Raised ICP is also known as intracranial hypertension and is defined as a sustained ICP of greater than 20 mm Hg. ICP is normally lower in children than adults, and may be subatmospheric in newborns. It must be emphasized that ICP is not just a number but its long-time dynamic must also be taken into consideration because some specific shapes of pressure waves can indicate pathologic states. The measurement of ICP can be done using invasive and non- invasive methods.Invasive methods of ICP measuring can be undertaken in different intracranial anatomical locations: intraventricular, intraparenchymal, epidural, subdural, and subarachnoidal. Ventriculostomy is considered the gold standard in terms of accurate measurement of pressure, although microtransducers are generally just as accurate. Ventriculostomy has also an advantage of being therapeutic method as well because excess of cerebrospinal fluid causing the raise of ICP can be easily drained. Both invasive techniques are associated with a minor risk of complications such as hemorrhage and infection. Furthermore, zero drift is a problem with selected microtransducers. Newer studies have questioned the benefit of the invasive intracranal pressure measurement.New methods of telemetric wireless measurement techniques are also emerging. Non-invasive methods include transcranial Doppler, tympanic membrane displacement, optic nerve sheath diameter, ocular pressure, near - infrared spectroscopy, CT scan and MRI. Those techniques are without the invasive methods risk of complication, but fail to measure ICP accurately enough to be used as routine alternatives to invasive measurement

Etiology, incidence and mortality in patients with ventilator-associated pneumonia in adult general surgery and cardiac surgery intensive care units in University Hospital Dubrava

Pneumonija povezana s mehaničkom ventilacijom (engl. ventilator-associated pneumonia, VAP) i pneumonija stečena u bolnici (engl. hospital acquired pneumonia, HAP) snažno doprinose pobolu i smrtnosti u jedinicama za intenzivno liječenje. Bolnička pneumonija se javlja 48 sati nakon prijema u bolnicu i čini se da za vrijeme prijema nema inkubacije. Pneumonija povezana s mehaničkom ventilacijom (VAP) je vrsta bolničke pneumonije koja se razvija kod intubiranih bolesnika nakon više od 48 sati mehaničke ventilacije. HAP i VAP predstavljaju uobičajene i ozbiljne komplikacije kod hospitaliziranih bolesnika. Budući se VAP i HAP dijagnoze rijetko dokumentiraju, željeli smo procijeniti učestalost pneumonija povezanih s mehaničkom ventilacijom u jedinicama intenzivnog liječenja opće i kardijalne kirurgije u 2018. godini. U analizu su uključeni bolesnici koji su intubirani i ventilirani više od 96 sati tijekom 2018. godine. Rezultati istraživanja pokazuju da je učestalost VAP-a u dvije jedinice za intenzivno liječenje u Kliničkoj bolnici Dubrava u skladu s učestalošću VAP-a utvrđenom u literaturi zahvaljujući provođenju uspješnih preventivnih strategija i pravodobnog započinjanja antimikrobne terapije i drugih dodatnih procedura.Ventilator-associated pneumonia (VAP) and hospital acquired pneumonia (HAP) strongly contribute to morbidity and mortality in intensive care units. Hospital acquired pneumonia (HAP) is pneumonia occurring 48 hours upon admission and appears not to be incubating at the time of admission. Ventilator-associated pneumonia (VAP) is a type of HAP developing in intubated patients after more than 48 hours upon mechanical ventilation. HAP and VAP are common and serious complications present in hospitalized patients. Since the diagnosis of VAP and HAP are rarely documented, we wanted to assess the incidence of VAP in General Surgery and Cardiac Surgery Intensive Care Units in 2018 and analyse the patients and procedures related factors. Patients intubated and ventilated more than 96 hours during 2018 were included. Our findings have shown that incidence of VAP in two analysed ICUs in UH Dubrava is in line with VAP incidence found in literature due to successful preventive strategies and timely initiation of antimicrobial therapy and other adjunctive procedures

Epidemiological characteristics, baseline clinical features, and outcomes of critically ill patients treated in a coronavirus disease 2019 tertiary center in continental Croatia

Aim To describe epidemiological characteristics and base - line clinical features, laboratory findings at intensive care unit (ICU) admission, and survival rates of critically ill coro - navirus disease 2019 (COVID-19) patients treated at a ter - tiary institution specialized for COVID-19 patients. Methods This retrospective study recruited 692 patients (67.1% men). Baseline demographic data, major comorbid - ities, anthropometric measurements, clinical features, and laboratory findings at admission were compared between survivors and non-survivors. Results The median age was 72 (64-78) years. The median body mass index was 29.1 kg/m 2 . The most relevant comor - bidities were diabetes mellitus (32.6%), arterial hyperten - sion (71.2%), congestive heart failure (19.1%), chronic kid - ney disease (12.6%), and hematological disorders (10.3%). The median number of comorbidities was 3 and median Charlson Comorbidity Index (CCI) was 5. A total of 61.8% patients received high-flow nasal oxygen therapy (HFNO) and 80.5% received mechanical ventilation (MV). Median duration of HFNO was 3, and that of MV was 7 days. ICU mortality rate was 72.7%. Survivors had significantly lower age, number of comorbidities, CCI, sequential organ failure assessment score, serum ferritin, C-reactive protein, D-dim - er, and procalcitonin, interleukin-6, lactate, white blood cell, and neutrophil counts. They also had higher lymphocyte counts, Pa O 2 /FiO 2 ratio, and glomerular filtration rate at ad - mission. Length of ICU stay was 9 days. The median surviv - al was 11 days for mechanically ventilated patients, and 24 days for patients who were not mechanically ventilated. Conclusion The parameters that differentiate survivors from non-survivors are in agreement with published data. Further multivariate analyses are warranted to identify in - dividual mortality risk factor

Bacterial superinfections in critically ill COVID-19 patients – experiences from University Hospital Dubrava tertiary COVID-19 center

Cilj istraživanja: Utvrditi incidenciju najčešćih bakterijskih superinfekcija, distribuciju uzročnika ovisno o sijelu infekcije, demografske podatke, relevantne laboratorijske i kliničke parametre te ishode liječenja kritično oboljelih bolesnika liječenih u tercijarnom regionalnom centru specijaliziranom za liječenje COVID-19 bolesnika PRIC KB Dubrava. Ispitanici i metode: Provedeno je retrospektivno opservacijsko ispitivanje te su podaci skupljeni pregledom povijesti bolesti u bolničkom informacijskom sustavu (BIS, In2, Zagreb) pacijenata liječenih u jedinicama intenzivne medicine PRIC-IC KB Dubrava tijekom razdoblja od 01. ožujka 2020. do 01. veljače 2021. Skupljeni podaci analizirani su u statističkom programskom paketu jamovi. Rezultati: Od ukupno 692 pacijenta, 383 je razvilo bakterijsku ili gljivičnu superinfekciju. Njih 305 je razvilo pneumoniju, 133 bakterijemiju a 120 urinarnu infekciju. 66,3% pacijenata bilo je muškog spola, te su češće primani sa bolničkih odjela i JIM-ova drugih bolnica. Od 305 pacijenata sa pneumonijom 295 je bilo mehanički ventilirano te je razvilo VAP. Kod pacijenata koji nisu razvili bakterijemiju primjećen je porat omjera neutrofili leukociti, te limfopenija i pad vrijednosti CRP-a. Urinarna infekcija češća je kod žena. U sve tri skupine, pacijenti su imali produljen period boravka u JIM-u i u bolnici. Zaključci: Incidencija bakterijskih superinfekcija u kritično oboljelih COVID-19 pacijenata vrlo je visoka i iznosi 55,3%. Najčešće bakterijske superinfekcije su VAP, bakterijemija i urinarna infekcija. Najčešći uzročni patogeni su MDR bakterije. Pacijenti sa sekundarnom infekcijom imaju dulji period boravka u JIM. Povećanje omjera neutrofili / limfociti i progresija limfopenije povezane su sa nepovoljnim kliničkim ishodima.Goal: To determine incidence of bacterial superinfections, causative pathogens demographic data, relevant laboratory parameters and outcomes in critically ill COVID-19 patients treated in primary respiratory intensivist center (PRIC) UH Dubrava. Patients and methods: In this retrospective observational study, clinical and laboratory data of 692 critically ill patients treated in PRIC UH Dubrava between March 1st 2020. and February 1st 2021. was collected using the hospital information system software (BIS) and statistical analysis was performed using the jamovi statistical package. Results: Out of 692 patients admitted to the ICU, 383 acquired bacterial or fungal superinfections. 305 acquired pneumonia, 133 bloodstream infections and 120 urinary infections. 66.3% of patients were males, and bacterial superinfections were more common in patients admitted from hospital wards or external ICUs. Out of 305 patients with pneumonia, 295 were receiving mechanical ventilation and satisfied the criteria for ventilator associated pneumonia. Patients with bloodstream infections maintained elevated neutrophil lymphocyte ratio, lymphopenia and elevated CRP levels on day 7 compared to those without BSI. Urinary infections were more common in females, and did not have an effect on outcomes. All patients that developed superinfections had prolonged ICU and hospital stay. Conclusion: Incidence of bacterial superinfections in critically ill COVID-19 patients is 55.3%. Most common infections are ventilator associated pneumonia, bloodstream infections and urinary infections. Most common pathogens are multi-drug resistant pathogens. Patients with bacterial superinfections have longer ICU and hospital stay, and in these patients, persistent elevation of NLR ratio and worsening of lymphopenia are characteristic for patients with worse outcomes

Measurement of intracranial pressure

U odraslih, intrakranijski prostor je zaštićen lubanjom, rigidnom strukturom sa stalnim unutarnjim volumenom od 1400 do 1700 mL. U fiziološkim stanjima , dijelovi intrakranijskog prostora su ( po volumenima): moždani parenhim – 80%, CST – 10%, i krv 10%. Monro- Kellieva doktrina govori da porast jednog od ovih volumena uzrokuje smanjenje ostala dva. Intrakranijski tlak može biti povišen u TOM-u, akutnom ishemijskom moždanom udaru opskrbnog područja velike arterije, intrakranijskom krvarenju i difuznim moždanim poremećajima poput meningitisa, encefalitisa te akutnog zatajenja jetre. Povećani IKT je poznat i kao intrakranijska hipertenzija i definiran je kao IKT veći od 20 mm Hg. IKT je normalno manji kod djece nego u odraslih, a može biti i subatmosferski u novorođenčadi. Mora se naglasiti da IKT nije samo broj nego se moraju uzeti u obzir dugotrajno mjerenje odnosno izgled valova tlaka koji mogu ukazivati na određena patološka stanja. Mjerenje IKT-a može se vršiti invazivno i neinvazivno. Invazivna mjerenja mogu se vršiti na različitim anatomskim mjestima: intraventrikularno, intraparenhimski, epiduralno, subduralno i subarahnoidalno te sa različitim senzorima: tekućinom spojenih, mikroprijenosnika te pneumatskih. VDL se smatra zlatnim standardom zbog preciznosti mada su i senzori s mikroprijenosnikom gotovo jednako precizni. VDL ima isto prednost jer je ujedno i terapijska metoda dreniranja viška likvora koja uzrokuje porast IKT-a. Obje metode povezane su s komplikacijama poput krvarenja i infekcija. Nadalje, nulti pomak je problem povezan s određenim mikroprijenosnicima. Novije studije dovode u pitanje svrhovitost invazivnog mjerenja IKT-a. Pojavljuju se i novije metode telemetrijskog bežičnog mjerenja. Neinvazivne tehnike mjerenja su TCD, mjerenje pomaka bubnjića, ONSD, NIRS, mjerenje OT-a, te korištenje CT-a i MRI-a. Te tehnike nemaju komplikacije povezane s invazivnim pristupom ali nisu pokazale preciznost mjerenja dovoljno veliku kako bi se rutinski primjenjivale.In adults, the intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume of 1400 to 1700 mL. Under physiologic conditions, the intracranial contents include (by volume) : brain parenchyma — 80 percent, cerebrospinal fluid — 10 percent and blood — 10 percent. Monroe -Kellie doctrine states that the rise in one of those volumes will cause decrease in other two. Intracranial pressure (ICP) can be elevated in traumatic brain injury, large artery acute ischemic stroke, intracranial hemorrhage, intracranial neoplasms, and diffuse cerebral disorders such as meningitis, encephalitis, and acute hepatic failure. Raised ICP is also known as intracranial hypertension and is defined as a sustained ICP of greater than 20 mm Hg. ICP is normally lower in children than adults, and may be subatmospheric in newborns. It must be emphasized that ICP is not just a number but its long-time dynamic must also be taken into consideration because some specific shapes of pressure waves can indicate pathologic states. The measurement of ICP can be done using invasive and non- invasive methods.Invasive methods of ICP measuring can be undertaken in different intracranial anatomical locations: intraventricular, intraparenchymal, epidural, subdural, and subarachnoidal. Ventriculostomy is considered the gold standard in terms of accurate measurement of pressure, although microtransducers are generally just as accurate. Ventriculostomy has also an advantage of being therapeutic method as well because excess of cerebrospinal fluid causing the raise of ICP can be easily drained. Both invasive techniques are associated with a minor risk of complications such as hemorrhage and infection. Furthermore, zero drift is a problem with selected microtransducers. Newer studies have questioned the benefit of the invasive intracranal pressure measurement.New methods of telemetric wireless measurement techniques are also emerging. Non-invasive methods include transcranial Doppler, tympanic membrane displacement, optic nerve sheath diameter, ocular pressure, near - infrared spectroscopy, CT scan and MRI. Those techniques are without the invasive methods risk of complication, but fail to measure ICP accurately enough to be used as routine alternatives to invasive measurement

Distribution of Pathogens and Predictive Values of Biomarkers of Inflammatory Response at ICU Admission on Outcomes of Critically Ill COVID-19 Patients with Bacterial Superinfections—Observations from National COVID-19 Hospital in Croatia

Background: Superinfections contribute to mortality and length of stay in critically ill COVID-19 patients. The aim of this study was to determine the incidence and pathogen distribution of bacterial and fungal superinfections of the lower respiratory tract (LRTI), urinary tract (UTI) and bloodstream (BSI) and to determine the predictive value of biomarkers of inflammatory response on their ICU survival rates. Methods: A retrospective observational study that included critically ill COVID-19 patients treated during an 11-month period in a Croatian national COVID-19 hospital was performed. Clinical and diagnostic data were analyzed according to the origin of superinfection, and multivariate regression analysis was performed to determine the predictive values of biomarkers of inflammation on their survival rates. Results: 55.3% critically ill COVID-19 patients developed bacterial or fungal superinfections, and LRTI were most common, followed by BSI and UTI. Multidrug-resistant pathogens were the most common causes of LRTI and BSI, while Enterococcus faecalis was the most common pathogen causing UTI. Serum ferritin and neutrophil count were associated with decreased chances of survival in patients with LRTI, and patients with multidrug-resistant isolates had significantly higher mortality rates, coupled with longer ICU stays. Conclusion: The incidence of superinfections in critically ill COVID-19 patients was 55.3%, and multidrug-resistant pathogens were dominant. Elevated ferritin levels and neutrophilia at ICU admission were associated with increased ICU mortality in patients with positive LRTI

Epidemiological characteristics, baseline clinical features, and outcomes of critically ill patients treated in a coronavirus disease 2019 tertiary center in continental Croatia

Aim: To describe epidemiological characteristics and baseline clinical features, laboratory findings at intensive care unit (ICU) admission, and survival rates of critically ill coronavirus disease 2019 (COVID-19) patients treated at a tertiary institution specialized for COVID-19 patients. ----- Methods: This retrospective study recruited 692 patients (67.1% men). Baseline demographic data, major comorbidities, anthropometric measurements, clinical features, and laboratory findings at admission were compared between survivors and non-survivors. ----- Results: The median age was 72 (64-78) years. The median body mass index was 29.1 kg/m2. The most relevant comorbidities were diabetes mellitus (32.6%), arterial hypertension (71.2%), congestive heart failure (19.1%), chronic kidney disease (12.6%), and hematological disorders (10.3%). The median number of comorbidities was 3 and median Charlson Comorbidity Index (CCI) was 5. A total of 61.8% patients received high-flow nasal oxygen therapy (HFNO) and 80.5% received mechanical ventilation (MV). Median duration of HFNO was 3, and that of MV was 7 days. ICU mortality rate was 72.7%. Survivors had significantly lower age, number of comorbidities, CCI, sequential organ failure assessment score, serum ferritin, C-reactive protein, D-dimer, and procalcitonin, interleukin-6, lactate, white blood cell, and neutrophil counts. They also had higher lymphocyte counts, PaO2/FiO2 ratio, and glomerular filtration rate at admission. Length of ICU stay was 9 days. The median survival was 11 days for mechanically ventilated patients, and 24 days for patients who were not mechanically ventilated. ----- Conclusion: The parameters that differentiate survivors from non-survivors are in agreement with published data. Further multivariate analyses are warranted to identify individual mortality risk factors