Hemorrhagic shock as a complication of anticoagulant therapy following the mitral valve replacement

This report describes a case of the hemorrhagic shock in a patient on the anticoagulant therapy supplementing implanted mechanical prosthetic heart valve replacing the mitral valve. The association between hemorrhagic shock, mechanical prosthetic heart valve and anticoagulant therapy is briefly discussed

Hemorrhagic shock as a complication of anticoagulant therapy following the mitral valve replacement

This report describes a case of the hemorrhagic shock in a patient on the anticoagulant therapy supplementing implanted mechanical prosthetic heart valve replacing the mitral valve. The association between hemorrhagic shock, mechanical prosthetic heart valve and anticoagulant therapy is briefly discussed

The Relationship between Prolonged Cerebral Oxygen Desaturation and Postoperative Outcome in Patients Undergoing Coronary Artery Bypass Grafting

58 patients who underwent on-pump coronary artery bypass graft surgery were evaluated for changes in regional cerebral oxygen saturation (rSO2) measured by near infrared spectroscopy (NIRS). If rSO2 during the operation fell to more than 20% under the baseline, standardized interventions were undertaken to maintain rSO2. Despite those interventions, in some cases we observed inability to maintain rSO2 above this threshold. Therefore we divided patients in two subgroups: 1. without prolonged rSO2 desaturation; 2. with prolonged rSO2 desaturation (area under the curve >150 min% for rSO250 min% for rSO2<50% of absolute value). The data were analyzed to determine whether there were major differences in outcome of these two groups. 18 out of 58 patients (31%) had prolonged rSO2 desaturation during operation. There was significantly higher number of diabetic patients in group with prolonged rSO2 desaturation (p=0.02). Intraoperative data revealed significantly more blood consumption during cardiopulmonary bypass (p=0.007) and the need for inotropes (p=0.04) in desaturation group. Three patients in prolonged desaturation group and no one in another group had stroke, coma or stupor (p=0.03). Logistic regression analysis revealed diabetes mellitus and age as predictors for prolonged rSO2 desaturation. We concluded that prolonged intraoperative rSO2 desaturation is significantly associated with worse neurological outcome in patients – nonresponders to standardized interventions for prevention of rSO2 desaturation

BORA ON THE NORTHERN ADRIATIC COAST DURING THE ALPEX SOP 20-25 MARCH 1982

Results from investigation of the bora during the period of 20-25 March 1982 are characterized by a large variability od bora strength, direction and duration. The two distinct wind speed maxima indicate two different origins of bora genesis. The first bora (21 March) was caused by a cold air stream, followed by the Genova cyclogenesis process. The second bora situation (23-25 March) is connected with the central Eyrope anticyclone and the cold NE flow - upstream of the Dinaric Alps. Assuming that the bora has a certain similarity with the supercritical flows described by hydraulic theory, the parameters of the real flow could be successfully predicted on the entire northern Adriatic in the case with the strongest bora

Rezultati ugradnje Levitronix Centrimag mehaničke potpore srcu u Kliničkom bolničkom centru Zagreb

Background: The management of end stage heart failure has been revolutionized by the use of mechanical circulatory support. The Levitronix Centrimag ventricular assist device (VAD) is designed for short-term cardiac assistance as a bridge to a more permanent solution to the hemodynamic problem. It has been used as bridge-to-transplantation, bridge-to-bridge, bridge-to-recovery, and bridge-to-decision. Methods: In the period between September 2008 and November 2009, six patients received mechanical cardiac assistance with the Levitronix Centrimag device at our institution. In one patient, the indication was postcardiotomy cardiogenic shock. In the remaining five patients, the device was implanted electively, due to progressive decompensation of chronic heart failure unresponsive to medical therapy. Results: The patient having received a biventricular assist device (BIVAD) in the postcardiotomy setting was 65 years of age. His ejection fraction and EuroSCORE were 20 % and 25, respectively. His NT-pro-BNP was 9,428 pg/ml and his pre-implantation lactate was 8.8 mmol/L. The mean age in the group of patients, in whom the VAD was placed due to decompensated severe heart failure (DSHF ), was 46 ± 11 years. Their ejection fraction and logistic EuroSCORE were 16 ± 2 % and 28 ± 7, respectively. The preoperative serum lactate and NT-pro-BNP concentrations were 1.7±0.8 mmol/L and 9577 ± 3674 pg/ml, respectively. Of these, three patients had evidence of end organ dysfunction. The low cardiac output was responsible for acute renal failure, requiring renal replacement therapy in one patient. Neurocognitive dysfunction and renal failure not requiring dialysis was seen in another. The third patient had long standing primary hepatic insufficiency. A reversal of end organ dysfunction was seen in the former two patients, whereas the hepatic insufficiency was not caused by hemodynamic compromise and was, therefore, not relieved by circulatory support. The single patient, who had suffered from postcardiotomy cardiogenic shock, died shortly after receiving mechanical circulatory support. Three of five patients, in whom Levitronix Centrimag was placed electively, were successfully transplanted. The remaining two died of septic complications. In the cohort of patients, in whom ventricular assistance was placed due to DSHF , two required BIVAD placement, and three left ventricular assist devices (LVAD). Conclusion: The Levitronix Centrimag VAD is useful in supporting circulation in patients with acute decompensation of congestive heart failure. It may also be used in patients with postcardiotomy shock. It is an imperative for the device to be placed before irreversible organ dysfunction occurs as the aftermath of malperfusion.Uvod: Liječenje terminalne faze srčanog popuštanja je revolucionarizirano uvođenjem mehaničke potpore srcu. Levitronix Centrimag je uređaj dizajniran u svrhu kratkoročne hemodinamske potpore prije nego što trajnije rješenje cirkulatornog problema postane moguće. Do sad se primijenjivao kao podrška srcu do transplantacije srca, do oporavka srčane funkcije ili do ugradnje trajnijeg oblika mehaničke potpore srcu. Metode: U periodu između rujna 2008 i studenog 2009 Levitronix Centrimag je u našoj ustanovi ugrađen u 6 bolesnika. U jednog bolesnika radilo se o postkardiotomijskom sindromu niskog minutnog volumena. U preostalih pet bolesnika ovaj je oblik mehaničke potpore srcu ugrađen elektivno radi progresivnog kliničkog pogoršanja bolesnika u terminalnoj fazi srčanog popuštanja koje je postalo rezistentno na konzervativnu terapiju. Rezultati: Bolesnik u kojeg je indikacija za mehaničkom potporom srcu bila postavljena hitno u postkardiotomijskom srčanom popuštanju bio je 65 godina star. Imao je ejekcijsku frakciju od 20% dok mu je logistički EuroSCORE bio 25. Prijeoperacijski NT-pro-BNP bio je 9428 pg/ ml dok su serumske vrijednosti laktata prije implantacije Centrimaga bile 8.8 mmol/L. Prosječna dob u skupini bolesnika u kojih je indikacija za mehaničku potporu srcu bila progresivna dekompenzacija srčane funkcije bila je 46 ± 11 godinu. Navedeni bolesnici su imali prosječnu ejekcijsku frakciju od 16 ± 2% dok im je logistički EuroSCORE bio 28 ± 7. Prijeoperacijske vrijednosti serumskog laktata i NT-pro-BNP bile su 1.7±0.8 mmol/L i 9577 ± 3674 pg/ml. U troje bolesnika bila je evidentna kompromitacija funkcije nekog od ostalih organskih sustava. U jednog bolesnika se radilo o akutnom renalnom zatajenju ovisnog o hemodijalizi, u drugog o neurokognitivnoj disfunkciji praćenog sa bubrežnim zatajenjem ali bez potrebe za dijalizom. U trećeg bolesnika radilo se o primarnoj hepatalnoj insuficijenciji. U prva dva bolesnika došlo je do poboljšanja organskih funkcija nakon uspostave mehaničke potpore srcu, dok u trećeg bolesnika nije došlo do promjene hepatalne funkcije budući da ista nije bila uzrokovana malperfuzijom. Bolesnik u kojeg je mehanička potpora srcu stavljena zbog postkardiotomijskog kardiogenog šoka je umro. Troje od pet bolesnika kod kojih je Levitronix Centrimag ugrađen radi dekompenzacije kroničnog zatajenja srca su uspješno transplantirani. Preostalo dvoje bolesnika je umrlo od septičnih komplikacija. U kohorti bolesnika u kojoj je mehanička potpora srcu ugrađena elektivno, dvoje bolesnika je zahtijevalo potporu oba ventrikula dok je u troje ugrađena potpora samo lijevom. Zaključak: Levitronix Centrimag pruža efikasnu hemodinamsku potporu bolesnicima sa kompromitiranom srčanom funkcijom. Neophodno je započeti sa mehaničkom potporom srcu prije nego što se pojave ireverzibilne disfunkcije ostalih organskih sustava

PREOPERATIVE ANAESTHESIOLOGIC EVALUATION OF PATIENT WITH KNOWN ALLERGY

Anaphylaxis is an unanticipated systemic hypersensitivity rea ction which can produce deleterious effects, even death, if not treated promptly. Preventive approach implies taking a thorough anamnesis with the emphasis on previously diagnosed allergies. If an allergic reaction occurred during previous surgery, a detailed documentation of administered anaesthetic agents and drugs would be crucial for the following anaesthesiologic management. Preoperative planning and avoiding cross-reactivity with drugs commonly used during anaesthesia are the key points to prevent an anaphylaxis. In case of emergency surgery when the exact identification of allergens is not possible, premedication prophylaxis should be considered. General measures for prevention of anaphylaxis could be undertaken as well, such as the choice of anaesthesiologic drugs and techniques in the operating theatre adequately equipped for the management of predictable anaphylaxis

Anesthesia management of a patient with heart transplant for non-cardiac surgery – case report and literature review

Od prve transplantacije srca 1967. u svijetu se na godinu izvede oko 3500 novih transplantacija srca, uz prosječno posttransplantacijsko preživljenje od 15 godina. Danas je sve češće da skupina pacijenata s transplantiranim srcem bude podvrgnuta nekardijalnim operacijama, što je novi izazov za anesteziološko zbrinjavanje zbog patofizioloških i farmakoloških interakcija s denerviranim presatkom srca, nuspojava imunosupresivne terapije, rizika od infekcije i odbacivanja transplantata. U ovom prikazu pacijentici s transplantiranim srcem potpuno je uklonjena štitnjača (tiroidektomija) zbog papilarnog karcinoma štitnjače. Pacijentica je bila I. kategorije prema klasifikaciji NYHA-e (New York Heart Association) i III. kategorije prema klasifikaciji ASA-e (American Society of Anesthesiologists), uz urednu funkciju alopresatka i stabilan sinusni ritam. Zahvat je izveden u općoj endotrahealnoj anesteziji. Neuromuskularni blok prekinut je sugamadeksom (Bridion®, Merck) i bolesnica je otpuštena kući nakon 3 dana.Since the first human cardiac transplantation in 1967, approximately 3,500 heart transplants are performed every year in the world and post-operation survival period average is 15 years. Due to these facts these patients are now presenting for various non-cardiac procedures. The information regarding the physiological and pharmacological interactions in a denervated allograft heart, the side-effects of immunosuppression, the risk of infection, and the potential for rejection is essential for anesthetic management. This case report reviews the anesthetic management of a heart transplant recipient undergoing a total thyroidectomy. She was NYHA I, ASA grade III with normal alograft function and sinus rhythm. Anesthesia was performed in general endotracheal anesthesia. Neuromuscular block was reversed with sugammadex and she was discharged after three days