Physiology and Pharmacology of Epidurally Administered Drugs

In the last few decades, epidural administration of various drugs has gained popularity and widespread clinical acceptance. Epidural administration of local anesthetics and opioids has been considered “state of the art” in acute pain management (thoracic and major abdominal surgery, labor). Its advantage is that it yields profound, long-lasting, dose-dependent analgesia, leaving other sensory and motor functions intact. It facilitates early patient mobilization and ambulation and therefore reduces the risk of postoperative thromboembolism and respiratory complications. The increment in the elderly population caused an increase in musculoskeletal and spine diseases and thus, epidural steroid injections have become highly effective for chronic pain treatment. There are many factors that have an impact on drug physiology and pharmacology in the epidural space and, therefore, can modify epidural anesthesia or the expected effect of another medication. This chapter provides insight into this complex and comprehensive topic to demonstrate a predictable pattern that can provide a safe and accurate guide to clinical practice

The incidence of nosocomial infections in patients with isolated severe traumatic brain injury

Abstract: Introduction: Traumatic brain injury is the leading cause of death in children and adults in developed countries. Severe traumatic brain injury is classified with Glasgow Coma Scale score 8 and less. About 50% of patients with severe traumatic brain injury developes at least one infection as a complication of primary condition during hospitalization in the Intensive Care Unit, resulting with fatal outcome in 28% of patients. Ventilator — associated pneumonia is the leading infection that affects patients with severe traumatic brain injury, with an incidence between 41% and 74%. Following are sepsis and urinary tract infections. The aim: To analyze the number of patients with nosocomial infection and isolated severe traumatic brain injury hospitalized in the Intensive Care Unit of the Clinical Hospital Centre Rijeka, Croatia, from 31 st January 2013 to 31 st December 2014. Patients and methods: A two – year retrospective study included 46 patients with isolated severe traumatic brain injury and nosocomial infection hospitalized in the Intensive Care Unit of the Clinical Hospital Centre Rijeka,Croatia, in the period from 31 st January 2013 to 31 st December 2014. All medical data was collected from the Division of Intensive Care Unit, Clinical Hospital Centre Rijeka, Croatia. Results: From 67 patients with isolated severe traumatic brain injury, 46 (68,65%) of them developed nosocomial infection. There was statistically significant more male patients than female (p < 0.05). The average age of infected patients was 57,8 years. The leading were the infections of the respiratory system. Gram – negative bacteria Proteus mirabilis and Pseudomonas aerugnonsa were the leading pathogens. The average duration of the infection was 5,77 day. Duration of mechanical ventilation accounted for the majority of the patients more than 10 days. The average duration of treatment for all 46 patients was 10,475 days, and for 16 (34,78%) of them, the treatment outcome was lethal. Conclusion: Nosocomial infections are becoming a major public health problem. The emphasis must be set on the prevention which includes maintaining the hygiene and the antiseptic rules among the medical personnel of the Intensive Care Unit. Already developed infections must be adequately treated so the negative treatment outcomes can be reduced

DVOGODIŠNJA RETROSPEKTIVNA ANALIZA INCIDENCIJE NOZOKOMIJALNIH INFEKCIJA U BOLESNIKA S IZOLIRANOM TEŠKOM OZLJEDOM MOZGA HOSPITALIZIRANIH U JEDINICI INTENZIVNOG LIJEČENJA KLINIČKOG BOLNIČKOG CENTRA RIJEKA

Svrha rada: analizirati broj bolesnika s izoliranom teškom ozljedom mozga, liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2014. godine, koji su za vrijeme liječenja u JIL-u oboljeli od infekcije, utvrditi učestalost i vrstu infekcija, utvrditi najčešće uzročnike kao i najčešće korištene antibiotike u liječenju bolesnika, analizirati podatke o trajanju infekcije, duljini i ishodu liječenja. Ispitanici i postupci: retrospektivna dvogodišnja analiza obuhvatila je ukupno 46 bolesnika s izoliranom teškom ozljedom mozga i nozokomijalnom infekcijom liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2013. godine te u razdoblju od 1. siječnja 2014. godine do 31. prosinca 2014. godine. Rezultati: od ukupno 67 bolesnika s izoliranom teškom ozljedom mozga, 46 (68,65%) bolesnika razvilo je nozokomijalnu infekciju. Prosječna dob inficiranih bolesnika bila je 57,8 godina. Padovi su bili glavni uzrok ozljede mozga u 67,39% bolesnika. Prevladavale su infekcije respiratornog sustava. Najčešći uzročnici bili su Proteus mirabilis te Pseudomonas aeruginosa. Beta – laktamski i cefalosporinski antibiotici najčešće su korišteni u liječenju. Prosječno trajanje infekcije iznosilo je 5,77 dana. Prosječna duljina liječenja u JIL-u bila je 10,47 dana uz smrtni ishod u 34,78% bolesnika. Zaključak: godišnje oko 70% bolesnika s izoliranom teškom ozljedom mozga razvije nozokomijalnu infekciju. Statistički značajno obolijeva više muškaraca u odnosu na žene. Najveći broj inficiranih bolesnika ima teže poremećaje svijesti popraćene razvitkom prvenstveno respiratornih infekcija uz ishode liječenja koji za veći broj bolesnika završavaju preživljenjem.Aims of research: to analyze the number of patients with isolated severe traumatic brain injury hospitalized in the Intensive Care Unit (ICU) of the Clinical Hospital Centre Rijeka from January 1st, 2013 to December 31st, 2014, who develop infection during their hospitalization; to analyze the incidence and type of infection; to analyze the most common pathogens and the most commonly used antibiotics in the therapy of this group of patients; to analyze the duration of infection and hospitalization so as the treatment outcomes. Examinees and actions: a two – year retrospective analysis included 46 patients with isolated severe traumatic brain injury and nosocomial infection hospitalized in the ICU of the Clinical Hospital Centre Rijeka in the period from January 1st, 2013 to December 31st, 2013 and in the period from January 1st, 2014 to December 31st, 2014. Results: from 67 patients with isolated severe traumatic brain injury, 46 (68,65%) of them developed nosocomial infection. The average age of infected patients was 57,8 years. Falls were the most common causes of brain injury in 67,39% of patients. On the first place were the infections of the respiratoy system. The most common pathogens were Proteus mirabilis and Pseudomonas aeruginosa. Beta – lactam and cephalosporin group of antibiotics where most commonly used in the treatment of infected patients. The average duration of the infection was 5,77 days. The average length of treatment in the ICU was 10,47 days with fatal outcome in 34,78% patients. Conclusion: Yearlly about 70% of all patients with isolated severe traumatic brain injury develop an nosocomial infection. It is statistically significant more infected men than women. The largest number of patients has severe disorders of levels of consciousness which are accompanied, in the first place, by respiratory infections and positive treatment outcomes for the most of the patients

DVOGODIŠNJA RETROSPEKTIVNA ANALIZA INCIDENCIJE NOZOKOMIJALNIH INFEKCIJA U BOLESNIKA S IZOLIRANOM TEŠKOM OZLJEDOM MOZGA HOSPITALIZIRANIH U JEDINICI INTENZIVNOG LIJEČENJA KLINIČKOG BOLNIČKOG CENTRA RIJEKA

Svrha rada: analizirati broj bolesnika s izoliranom teškom ozljedom mozga, liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2014. godine, koji su za vrijeme liječenja u JIL-u oboljeli od infekcije, utvrditi učestalost i vrstu infekcija, utvrditi najčešće uzročnike kao i najčešće korištene antibiotike u liječenju bolesnika, analizirati podatke o trajanju infekcije, duljini i ishodu liječenja. Ispitanici i postupci: retrospektivna dvogodišnja analiza obuhvatila je ukupno 46 bolesnika s izoliranom teškom ozljedom mozga i nozokomijalnom infekcijom liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2013. godine te u razdoblju od 1. siječnja 2014. godine do 31. prosinca 2014. godine. Rezultati: od ukupno 67 bolesnika s izoliranom teškom ozljedom mozga, 46 (68,65%) bolesnika razvilo je nozokomijalnu infekciju. Prosječna dob inficiranih bolesnika bila je 57,8 godina. Padovi su bili glavni uzrok ozljede mozga u 67,39% bolesnika. Prevladavale su infekcije respiratornog sustava. Najčešći uzročnici bili su Proteus mirabilis te Pseudomonas aeruginosa. Beta – laktamski i cefalosporinski antibiotici najčešće su korišteni u liječenju. Prosječno trajanje infekcije iznosilo je 5,77 dana. Prosječna duljina liječenja u JIL-u bila je 10,47 dana uz smrtni ishod u 34,78% bolesnika. Zaključak: godišnje oko 70% bolesnika s izoliranom teškom ozljedom mozga razvije nozokomijalnu infekciju. Statistički značajno obolijeva više muškaraca u odnosu na žene. Najveći broj inficiranih bolesnika ima teže poremećaje svijesti popraćene razvitkom prvenstveno respiratornih infekcija uz ishode liječenja koji za veći broj bolesnika završavaju preživljenjem.Aims of research: to analyze the number of patients with isolated severe traumatic brain injury hospitalized in the Intensive Care Unit (ICU) of the Clinical Hospital Centre Rijeka from January 1st, 2013 to December 31st, 2014, who develop infection during their hospitalization; to analyze the incidence and type of infection; to analyze the most common pathogens and the most commonly used antibiotics in the therapy of this group of patients; to analyze the duration of infection and hospitalization so as the treatment outcomes. Examinees and actions: a two – year retrospective analysis included 46 patients with isolated severe traumatic brain injury and nosocomial infection hospitalized in the ICU of the Clinical Hospital Centre Rijeka in the period from January 1st, 2013 to December 31st, 2013 and in the period from January 1st, 2014 to December 31st, 2014. Results: from 67 patients with isolated severe traumatic brain injury, 46 (68,65%) of them developed nosocomial infection. The average age of infected patients was 57,8 years. Falls were the most common causes of brain injury in 67,39% of patients. On the first place were the infections of the respiratoy system. The most common pathogens were Proteus mirabilis and Pseudomonas aeruginosa. Beta – lactam and cephalosporin group of antibiotics where most commonly used in the treatment of infected patients. The average duration of the infection was 5,77 days. The average length of treatment in the ICU was 10,47 days with fatal outcome in 34,78% patients. Conclusion: Yearlly about 70% of all patients with isolated severe traumatic brain injury develop an nosocomial infection. It is statistically significant more infected men than women. The largest number of patients has severe disorders of levels of consciousness which are accompanied, in the first place, by respiratory infections and positive treatment outcomes for the most of the patients

DVOGODIŠNJA RETROSPEKTIVNA ANALIZA INCIDENCIJE NOZOKOMIJALNIH INFEKCIJA U BOLESNIKA S IZOLIRANOM TEŠKOM OZLJEDOM MOZGA HOSPITALIZIRANIH U JEDINICI INTENZIVNOG LIJEČENJA KLINIČKOG BOLNIČKOG CENTRA RIJEKA

Svrha rada: analizirati broj bolesnika s izoliranom teškom ozljedom mozga, liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2014. godine, koji su za vrijeme liječenja u JIL-u oboljeli od infekcije, utvrditi učestalost i vrstu infekcija, utvrditi najčešće uzročnike kao i najčešće korištene antibiotike u liječenju bolesnika, analizirati podatke o trajanju infekcije, duljini i ishodu liječenja. Ispitanici i postupci: retrospektivna dvogodišnja analiza obuhvatila je ukupno 46 bolesnika s izoliranom teškom ozljedom mozga i nozokomijalnom infekcijom liječenih u Jedinici intenzivnog liječenja (JIL), Kliničkog bolničkog centra Rijeka u razdoblju od 1. siječnja 2013. godine do 31. prosinca 2013. godine te u razdoblju od 1. siječnja 2014. godine do 31. prosinca 2014. godine. Rezultati: od ukupno 67 bolesnika s izoliranom teškom ozljedom mozga, 46 (68,65%) bolesnika razvilo je nozokomijalnu infekciju. Prosječna dob inficiranih bolesnika bila je 57,8 godina. Padovi su bili glavni uzrok ozljede mozga u 67,39% bolesnika. Prevladavale su infekcije respiratornog sustava. Najčešći uzročnici bili su Proteus mirabilis te Pseudomonas aeruginosa. Beta – laktamski i cefalosporinski antibiotici najčešće su korišteni u liječenju. Prosječno trajanje infekcije iznosilo je 5,77 dana. Prosječna duljina liječenja u JIL-u bila je 10,47 dana uz smrtni ishod u 34,78% bolesnika. Zaključak: godišnje oko 70% bolesnika s izoliranom teškom ozljedom mozga razvije nozokomijalnu infekciju. Statistički značajno obolijeva više muškaraca u odnosu na žene. Najveći broj inficiranih bolesnika ima teže poremećaje svijesti popraćene razvitkom prvenstveno respiratornih infekcija uz ishode liječenja koji za veći broj bolesnika završavaju preživljenjem.Aims of research: to analyze the number of patients with isolated severe traumatic brain injury hospitalized in the Intensive Care Unit (ICU) of the Clinical Hospital Centre Rijeka from January 1st, 2013 to December 31st, 2014, who develop infection during their hospitalization; to analyze the incidence and type of infection; to analyze the most common pathogens and the most commonly used antibiotics in the therapy of this group of patients; to analyze the duration of infection and hospitalization so as the treatment outcomes. Examinees and actions: a two – year retrospective analysis included 46 patients with isolated severe traumatic brain injury and nosocomial infection hospitalized in the ICU of the Clinical Hospital Centre Rijeka in the period from January 1st, 2013 to December 31st, 2013 and in the period from January 1st, 2014 to December 31st, 2014. Results: from 67 patients with isolated severe traumatic brain injury, 46 (68,65%) of them developed nosocomial infection. The average age of infected patients was 57,8 years. Falls were the most common causes of brain injury in 67,39% of patients. On the first place were the infections of the respiratoy system. The most common pathogens were Proteus mirabilis and Pseudomonas aeruginosa. Beta – lactam and cephalosporin group of antibiotics where most commonly used in the treatment of infected patients. The average duration of the infection was 5,77 days. The average length of treatment in the ICU was 10,47 days with fatal outcome in 34,78% patients. Conclusion: Yearlly about 70% of all patients with isolated severe traumatic brain injury develop an nosocomial infection. It is statistically significant more infected men than women. The largest number of patients has severe disorders of levels of consciousness which are accompanied, in the first place, by respiratory infections and positive treatment outcomes for the most of the patients

Specificities of anesthesia management for kidney transplantation

Transplantacija bubrega predstavlja najbolju metodu liječenja terminalne faze kronične bubrežne bolesti. Pripremu pacijenata za zahvat vodi tim u koji su uključeni nefrolog, kirurg – urolog, anesteziolog te liječnik obiteljske medicine, čija je međusobna suradnja nezaobilazni dio skrbi o pacijentu. U prijeoperacijskoj pripremi anesteziolog se susreće s brojnim komorbiditetima, kompleksnom anamnezom te širokim spektrom pacijentove medikamentozne terapije uz naglasak na kardiovaskularne bolesti koje predstavljaju najčešći uzrok smrtnosti u ovoj skupini pacijenata. Pojavnost hematoloških, metaboličkih, respiratornih i endokrinih bolesti česta je, te je iznimno važna optimalizacija pacijentova općeg stanja prije operacijskog zahvata. Transplantacija bubrega je zahvat koji se obično ne može planirati i prema njemu se treba ponašati kao prema hitnom zahvatu, čime se povećava rizik razvoja komplikacija. Za vrijeme samog zahvata koji se izvodi u općoj, balansiranoj anesteziji, uloga anesteziologa je poznavanje farmakokinetike i farmakodinamike lijekova te vođenje anestezije koja će omogućiti urednu funkciju perfuzije presatka, što se postiže održavanjem adekvatnih vrijednosti krvnog tlaka. Važno je pravovremeno započinjanje antibiotske i imunosupresivne terapije uz zadovoljavajuću analgeziju. U daljnjem poslijeoperacijskom tijeku nužno je rano prepoznavanje i prevencija mogućih komplikacija kako bi se spriječilo neželjeno odbacivanje bubrežnog presatka.Kidney transplantation represents the best method for treating end-stage renal disease. The procedure is led by a team involving a nephrologist, a urologist, an anesthesiologist and a family medicine doctor whose cooperation is an indispensable part of patient care. The anesthesiologist encounters numerous patient’s comorbidities with a complex medical history and a wide range of medications. The emphasis is set on cardiovascular diseases which are the most common cause of mortality in this group of patients. The incidence of hematological, metabolic, respiratory and endocrine diseases is common, and it is extremely important to optimize the patient’s general condition prior to surgery. Kidney transplantation usually cannot be planned so it should be treated as an emergency, increasing the risk of complications. During the procedure that is performed under general, balanced anaesthesia, the role of the anesthesiologist is to know pharmacokinetics and pharmacodynamics of the drugs. Maintenance of blood pressure during anesthesia ensures an adequate kidney transplant perfusion. Early antibiotic and immunosuppressive therapy with satisfactory analgesia is important. In the postoperative course, early identification and prevention of possible complications is necessary to prevent unwanted kidney transplant rejection

THE INCIDENCE OF NOSOCOMIAL INFECTIONS IN PATIENTS WITH ISOLATED SEVERE TRAUMATIC BRAIN INJURY

Introduction: Traumatic brain injury is the leading cause of death in children and adults in developed countries. Severe traumatic brain injury is classified with Glasgow Coma Scale score 8 and less. About 50% of patients with severe traumatic brain injury developes at least one infection as a complication of primary condition during hospitalization in the Intensive Care Unit, resulting with fatal outcome in 28% of patients. Ventilator associated pneumonia is the leading infection that affects patients with severe traumatic brain injury, with an incidence between 41% and 74%. Following are sepsis and urinary tract infections. The aim: To analyze the number of patients with nosocomial infection and isolated severe traumatic brain injury hospitalized in the Intensive Care Unit of the Clinical Hospital Centre Rijeka, Croatia, from 31st  January 2013 to 31st December 2014. Patients and methods: A two year retrospective study included 46 patients with isolated severe traumatic brain injury and nosocomial infection hospitalized in the Intensive Care Unit of the Clinical Hospital Centre Rijeka,Croatia, in the period from 31st January 2013 to 31st December 2014. All medical data was collected from the Division of Intensive Care Unit, Clinical Hospital Centre Rijeka, Croatia. Results: From 67 patients with isolated severe traumatic brain injury, 46 (68,65%) of them developed nosocomial infection. There was statistically significant more male patients than female (p<0.05). The average age of infected patients was 57,8 years. The leading were the infections of the respiratory system. Gram negative bacteria Proteus mirabilis and Pseudomonas aerugnonsa were the leading pathogens. The average duration of the infection was 5,77 days. For 16 (34,78%) of 46 patients the treatment outcome was lethal. Conclusion: Nosocomial infections are becoming a major public health problem. The emphasis must be set on the prevention which includes maintaining the hygiene and the antiseptic rules among the Intensive Care Unit staff. Already developed infections must be adequately treated so the negative treatment outcomes can be reduced

Acute Liver Failure as the Leading Manifestation of Spontaneous Tumour Lysis Syndrome in a Patient with NonHodgkin Lymphoma: Do Current Diagnostic Criteria of Tumour Lysis Syndrome Need Re-Evaluation?

Tumour lysis syndrome (TLS) is a group of pathophysiological processes caused by rapid degradation of tumour cells with subsequent release of intracellular contents into the extracellular space. It is characterized by the development of systemic metabolic disturbances with or without clinical manifestations. The process usually occurs in highly proliferative, large tumours after induction of cytotoxic therapy. Rarely, however, spontaneous TLS can develop, as well as signs of multiorgan failure triggered by an excessive metabolic load and sterile inflammation. The combination of the aforementioned is thus quite unique. Here, we present a 63-year-old male in which spontaneous TLS was accompanied with acute liver failure and delineated underlying nonHodgkin lymphoma. Initial laboratory findings included hyperkalaemia, hyperphosphataemia, hypocalcaemia, uraemia, and increased creatinine levels indicating the onset of TLS with acute kidney injury. Moreover, the patient showed signs of jaundice, coagulopathy, and hepatic encephalopathy. Development of TLS with multiorgan failure prompted rapid initiation of critical care management, including vigorous intravenous fluid therapy, allopurinol treatment, high flow continuous venovenous haemodiafiltration, and commencement of chemotherapy. The case highlights the possibility of TLS as a differential diagnosis in patients presenting with multiorgan failure and the importance of early detection of this potentially challenging and fatal diagnosis

Real-Time PCR Quantification of 87 miRNAs from Cerebrospinal Fluid: miRNA Dynamics and Association with Extracellular Vesicles after Severe Traumatic Brain Injury

Severe traumatic brain injury (sTBI) is an intracranial damage triggered by external force, most commonly due to falls and traffic accidents. The initial brain injury can progress into a secondary injury involving numerous pathophysiological processes. The resulting sTBI dynamics makes the treatment challenging and prompts the improved understanding of underlying intracranial processes. Here, we analysed how extracellular microRNAs (miRNAs) are affected by sTBI. We collected thirty-five cerebrospinal fluids (CSF) from five sTBI patients during twelve days (d) after the injury and combined them into d1–2, d3–4, d5–6 and d7–12 CSF pools. After miRNA isolation and cDNA synthesis with added quantification spike-ins, we applied a real-time PCR-array targeting 87 miRNAs. We detected all of the targeted miRNAs, with totals ranging from several nanograms to less than a femtogram, with the highest levels found at d1–2 followed by decreasing levels in later CSF pools. The most abundant miRNAs were miR-451a, miR-16-5p, miR-144-3p, miR-20a-5p, let-7b-5p, miR-15a-5p, and miR-21-5p. After separating CSF by size-exclusion chromatography, most miRNAs were associated with free proteins, while miR-142-3p, miR-204-5p, and miR-223-3p were identified as the cargo of CD81-enriched extracellular vesicles, as characterised by immunodetection and tunable resistive pulse sensing. Our results indicate that miRNAs might be informative about both brain tissue damage and recovery after sTBI