Intensive care management of patients with left ventricular assist device

Mechanical circulatory support devices, especially left ventricular assist devices (LVADs) represent an important treatment modality for patients with end-stage heart failure (HF). In a 1-year period (from January to December 2017) in our intensive care unit (ICU) we had a total of 8 patients with LVAD implantation. LVADs are devices with unique physiology which restore tissue circulation by increasing blood supply, nevertheless, they can be challenging to manage and are associated with significant complications

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

Anestezija bez primjene opioida u kliničkoj praksi - pregledni rad

Currently, enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways with the goal to achieve early patient recovery after surgery with minimal postoperative complications. According to studies, opioid free general anesthesia has many perioperative benefits and should be part of the ERAS protocols in specific surgical and patient indications. Opioid free general anesthesia is a multimodal balanced technique that is based on the concept that opioids are not used preoperatively or intraoperatively until the patient has aroused. The basic concept of opioid free general anesthesia is intravenous administration of several nonopioid drugs that operate at different pharmacological sites blocking surgical stress and sympathetic activation response. Moreover, current studies have shown that opioid free anesthesia is a technique which satisfactorily controls postoperative pain as the fifth vital sign, and has minimal side effects and better patient recovery with the same surgical conditions as general multimodal balanced anesthesia. However, further research is needed.Primjena protokola ERAS (enhanced recovery after surgery) u svakodnevnoj anesteziološkoj i kirurškoj praksi omogućava brži oporavak bolesnika nakon operacije uz minimalne poslijeoperacijske komplikacije. Prema dosadašnjim istraživanjima opća anestezija bez primjene opioida trebala bi biti dio protokola ERAS u svakodnevnoj kliničkoj praksi u skladu s primjenom prema unaprijed određenim indikacijama s obzirom na vrstu operacije i status bolesnika. Opća anestezija bez opioida je multimodalna uravnotežena tehnika koja se temelji na konceptu da se opioidni lijekovi ne primjenjuju prijeoperacijski i intraoperacijski sve dok se bolesnik ne probudi iz anestezije. Iako su novija istraživanja pokazala prednosti anestezije bez opioida u odnosu na opću multimodalnu uravnoteženu anesteziju s primjenom opioida, daljnja istraživanja su potrebna

Who is the Patient? Disclosure of Information and Consent in Anesthesia and Intensive Care (Informed Consent)

Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the prac- tice, however with the vast advances in science and technology, numerous ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hip- pocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together repre- sent the complete best interest of the patient. This is the basic goal of the »Informed Consent«. The widening of legal boundaries regarding professional liability may consequentially lead to a »defensive medicine« and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evalu- ating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief, explain all the necessary information a »reasonable« anesthesiologist would disclose to a »reasonable« patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient

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

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

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications