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

Kombinirana uporaba videolaringoskopa i intubacijskog endoskopa BONFILS kao mogućnost zbrinjavanja otežanoga dišnog puta: prikaz slučaja

Difficult airway management poses a great challenge for clinicians, especially if it is unanticipated. Numerous guidelines and a wide array of devices constitute the anesthesiologist’s armamentarium for managing the airway. When the use of individual devices fails, the use of combination techniques is advised. We present a case of difficult intubation in a 50-year-old male patient scheduled for aortic valve replacement. He had no prior history of difficult airway management, and no abnormalities were detected on preoperative airway assessment. Body mass index was 29 kg/m2. After the separate use of direct laryngoscopy, videolaryngoscopy and a BONFILS intubation endoscope (BIE) had failed, we resorted to a combination technique, combining videolaryngoscopy and BIE. While the videolaryngoscope provided the space needed for BIE and visual guidance through copious secretions, the BIE served as a stylet for endotracheal tube guidance, leading to successful intubation. Since the technique requires costly equipment, experience in handling it and at least two operators, it is more appropriate as a rescue measure than an elective procedure. Given the potentially disastrous outcomes of failed intubation, mastering advanced airway management techniques remains of vital importance, and the combination technique is one of them.Otežani dišni put predstavlja velik izazov za kliničare, pogotovo ako je neočekivan. Anesteziolozima su na raspolaganju brojne smjernice i široka paleta pomagala za zbrinjavanje dišnoga puta, a kad pojedinačne tehnike zakažu, savjetuje se primjena kombiniranih tehnika. Predstavljamo slučaj otežane intubacije kod pedesetogodišnjeg muškarca kod kojega je planirana zamjena aortnog zalistka. Anamnezom nisu utvrđene ranije otežane intubacije. Prijeoperacijska procjena dišnoga puta bila je bez osobitosti. Indeks tjelesne mase iznosio je 29 kg/m2. Nakon neuspješne pojedinačne primjene direktne laringoskopije, videolaringoskopije i intubacijskog endoskopa BONFILS (BIE) primijenili smo kombiniranu tehniku kombinirajući videolaringoskop i BIE. Dok smo videolaringoskopom osigurali potreban prostor za plasiranje BIE i poboljšali prikaz kroz obilan sekret, BIE nam je poslužio kao vodilica za endotrahealni tubus, što je dovelo do uspješne intubacije. Budući da tehnika zahtijeva skupu opremu, iskustvo u njenoj primjeni te barem dva anesteziologa, prikladnija je kao izvanredna mjera nego kao redovni postupak. S obzirom na potencijalno katastrofalne posljedice neuspješne intubacije ovladavanje naprednim tehnikama zbrinjavanja dišnoga puta ostaje od ključne važnosti, a kombinirana tehnika jedna je od njih

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

A diagnosis of a renal injury by early biomarkers in patients exposed to cardiopulmonary bypass during cardiac surgery

We prospectively studied renal function in 158 patients scheduled for elective cardiac surgery with the use of cardiopulmonary bypass (CPB). The patients involved in this study had normal renal function as well as normal function of the left ventricle. The results of the study showed a statistically significant increase of early markers of renal injury Alpha-1-Microglobulin (A1M) and Neutrophil Gelatinase-Associated Lipocalin (NGAL), which were being traced in the patients’ urine 5 hours and 24 hours after CPB. In contrast with the aforementioned early markers, the so-called “classical” markers of renal injury – serum urea and creatinine – did not show a statistical significance of value increase after CPB. Using early factors of renal injury A1M and NGAL, the study managed to show slight, subclinical injuries of the proximal renal tubules after CPB and cardiac surgeries. The value of these factors lies in their early and precise detection of renal injury, which is a significant clinical parameter for monitoring renal function, especially after cardiac surgery with the use of CPB

EUROPEAN RESUSCITATION COUNCIL GUIDELINES FOR RESUSCITATION 2010

Osnovno održavanje života odraslih. – Svi spašavatelji, bilo osposobljeni ili ne, kod žrtava kardijalnog aresta moraju primijeniti vanjsku masažu srca. Cilj je pritisnuti prsni koš do dubine od najmanje 5 cm, frekvencijom od najmanje 100 kompresija u minuti, ali i dopustiti ponovo odizanje prsnog koša, te smanjiti prekide u kompresijama. Osposobljeni bi spašavatelji trebali primijeniti i ventilaciju s omjerom kompresija-ventilacija od 30:2. Liječenje strujom. – Mnogo je veći naglasak na smanjivanju trajanja stanki prije ili poslije defibrilacije; preporučuje se nastavak vanjske masaže srca tijekom punjenja defibrilatora. Potiče se daljnji razvoj programa automatskih vanjskih defibrilatora (AED). Napredno održavanje života odraslih. – Naglašena je važnost visokokvalitetnih kompresija na prsni koš tijekom provođenja ALS-a, koje se prekidaju samo kako bi se omogućili specifični postupci. Uklanja se preporuka o potrebi reanimacije tijekom određenog vremena prije defibrilacije nakon kardijalnog aresta izvan bolnice, kojemu nije svjedočilo osoblje hitne medicinske pomoći. Smanjena je uloga prekordijalnog udarca. Primjena lijekova putem endotrahealnog tubusa više se ne preporučuje, već se lijekovi moraju primijeniti intraosealnim (IO) pristupom. Atropin se više ne preporučuje za rutinsku primjenu tijekom asistolije ili električne aktivnosti bez pulsa. Smanjen je naglasak na ranu endotrahealnu intubaciju ako ju ne provodi visokostručna osoba uz najmanji mogući prekid vanjske masaže srca. Povećan je naglasak na uporabu kapnografije. Prepoznat je moguć štetan učinak hiperoksemije. Revidirana je preporuka za kontrolu glikemije. Preporučuje se primjena terapijske hipotermije kod komatoznih bolesnika nakon kardijalnog aresta povezanog s početnim ritmovima koji se defibriliraju, kao i onima koji se ne defibriliraju, za ove druge sa smanjenom razinom dokaza. Početno zbrinjavanje akutnih koronarnih sindroma. – Uveden je pojam infarkt miokarda bez ST-elevacije–akutni koronarni sindrom (NSTEMI-ACS) koji obuhvaća infarkt miokarda bez elevacije ST-spojnice i nestabilnu anginu pektoris. Primarna PCI (PPCI) najpoželjniji je reperfuzijski postupak, uz uvjet da ga obavi iskusan tim i u skladu s vremenskim okvirima. U liječenju bi trebalo izbjegavati nesteroidne protuupalne lijekove, rutinsku intravensku primjenu beta-blokatora i kisik – osim u slučaju hipoksemije, zaduhe ili zastoja na plućima. Održavanje života djece. – Odluka o započinjanju reanimacije mora se donijeti u manje od 10 sekundi. Laike treba podučavati reanimaciji s omjerom 30 kompresija naprama 2 ventilacije, a spašavatelji koji imaju dužnost odgovoriti na poziv trebaju primjenjivati omjer kompresije-ventilacije od 15:2, međutim, ako su sami, mogu primijeniti omjer od 30:2. Ventilacija i dalje ostaje vrlo važna sastavnica reanimacije asfiksijskog aresta. Naglasak je na postizanju kvalitetnih kompresija frekvencije najmanje 100, ali ne više od 120 u minuti, uz minimalne prekide. Automatski vanjski defibrilatori sigurni su i uspješni kada se primjenjuju kod djece starije od jedne godine. Za defibrilaciju kod djece preporučuje se jedna defibrilacija od 4 J/kg čija se jačina ne povećava. Sa sigurnošću se mogu rabi endotrahealni tubusi s balončićem i kod dojenčadi i kod mlađe djece. Monitoriranje izdahnutog ugljikova dioksida (CO2), najbolje kapnografijom, preporučuje se tijekom reanimacije. Reanimacija novorođenčadi na porodu. – Kod neugrožene novorođenčadi sada se preporučuje odgađanje podvezivanja pupčane vrpce od najmanje jedne minute nakon potpunog rođenja djeteta. Za donošenu novorođenčad, tijekom reanimacije pri porodu trebao bi se rabiti zrak. Za nedonoščad mlađu od 32 tjedna gestacije treba razumno primijeniti mješavinu kisika i zraka te primjena treba biti vođena pulsnim oksimetrom. Nedonoščad mlađu od 28 tjedana gestacije trebalo bi neposredno nakon rođenja potpuno do područja vrata omotati plastičnom folijom, bez sušenja. Preporučen omjer kompresija-ventilacija u reanimaciji novorođenčadi ostaje 3:1. Ne preporučuje se pokušavati aspirirati mekonij iz nosa i usta još nerođenog djeteta, dok mu je glava još na međici. Ako se daje adrenalin, preporučuje se intravenska primjena u dozi od 10 do 30 µg/kg. Kod terminske ili gotovo terminske novorođenčadi s umjerenom do teškom hipoksično-ishemijskom encefalopatijom preporučuje se terapijska hipotermija. Načela podučavanja reanimacije. – Cilj je osigurati da polaznici steknu i zadrže vještine i znanje koje će im omogućiti ispravno djelovanje tijekom stvarnoga kardijalnog aresta te poboljšati ishod bolesnika. Kratki video/kompjutorski tečajevi za samostalno učenje, s minimalnom ulogom instruktora ili bez njega, udruženi s praktičnom nastavom mogu se smatrati jednako učinkovitom alternativom tečajevima osnovnog održavanja života (BLS i AED) koje vode instruktori. U najboljem slučaju, svi bi građani trebali biti osposobljeni za standardnu KPR koja uključuje vanjsku masažu srca i ventilaciju. Znanje i vještine osnovnog i naprednog održavanja života smanjuju se u samo tri do šest mjeseci. Uređaji s glasovnim uputama tijekom reanimacije ili povratnim informacijama unaprjeđuju stjecanje i zadržavanje vještina.Basic Life Support. – All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Electrical therapies. – Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. Adult Advanced Life Support. – Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. Initial management of acute coronary syndromes. – The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta- blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. Paediatric Life Support. – The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. Resuscitation of babies at birth. – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10–30 µg /kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. Principles of education in resuscitation. – The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention

Report on the work of the Reference center for pediatric cardiology Ministry of Health of the Republic of Croatia

Cilj je ovog izvješća u proteklom trogodišnjem razdoblju (2019–2022) prikazati: 1) aktivnosti Referentnog centra, 2) postignute stručne rezultate i primjenu novih metoda, postupaka i unaprjeđenje struke, i 3) znanstvenu i stručnu suradnju s inozemnim ustanovama visoke razine. Rezultati: Referentni je centar jedino mjesto u Republici Hrvatskoj koje kontinuirano zbrinjava populaciju najugroženijih i najtežih bolesnika pedijatrijske dobi sa srčanom patologijom. Ima kontinuirano, 24 sata dostupnu kardiološku, kardiokiruršku, anesteziološku, neonatalnu i intenzivnu skrb za djecu sa složenim prirođenim i stečenim srčanim bolestima. Također su dostupne metode nadomještanja funkcije organa u zatajivanju (ECMO potpora, LVAD-BiVAD, Berlin-Heart pumpa, hemodijaliza, program transplantacije srca / drugih organa), a sve zahvaljujući timskom radu i suradnji tima nekoliko Zavoda. Izvode se složene kardiokirurške operacije u djece s prirođenim srčanim greškama uz jasan trend povećanja broja i složenosti operacija, te uz i dalje prihvatljivo nisku smrtnost. Danas smo u mogućnosti samostalno liječiti gotovo sve srčane bolesti u djece. Godišnje se izvede oko 200 kateterizacija srca u djece. Više od 40% čine intervencijske procedure, a više od 50% tih intervencija izvodi se u dojenačkom periodu. Tijekom protekle tri godine uvedeno je pet novih perkutanih intervencijskih metoda: liječenje nativne koarktacije i rekoarktacije umetanjem stenta, liječenje stenoze pulmonalnih grana umetanjem stenta, perkutano umetanje valvule na pulmonalnu poziciju, dilatacija postojećeg stenta te zatvaranje aortopulmonalnih kolaterala u djece s univentrikulskim srcem. Navedeni iskoraci učinjeni su kontinuiranim zalaganjem članova tima uz potporu i mentorstvo, odnosno kontinuiranu suradnju s inozemnim stručnjacima iz triju inozemnih ustanova (DeutschesHerzZentrum Muenchen, KinderherzZentrum Linz, Kids Heart Center Budapest). Zaključak: Naš centar stoji uz bok rijetkih centara u Europi koji su u mogućnosti izvesti navedene procedure. Navedene su aktivnosti rezultirale unaprjeđenjem kvalitete skrbi na razini RH i temelj su za daljnji planirani rast i razvoj struke u okvirima naše zemlje.The aim of this report is to show in the past three-year period (2019–2022): 1)activities of the Reference Center, 2)achieved professional results and the application of new methods, procedures, and improvement of the profession, and 3)scientific and professional cooperation with high-level foreign institutions. Results: The reference center is the only place in the Republic of Croatia that continuously cares for the population of the most vulnerable children with cardiac pathology. It has continuous, 24-hour cardiology, cardiac surgery, anesthesiology, neonatal and intensive care for children with complex congenital and acquired heart diseases. Organ function replacement are also available (ECMO support, LVAD-BiVAD, Berlin-Heart pump, hemodialysis, heart/other organ transplant program) thanks to the teamwork and cooperation of different Departments. Complex cardiac surgeries are performed in children with a clear trend of increasing the number and complexity of surgeries, with low mortality. Today, we can independently treat almost all congenital heart defects in children. About 200 cardiac catheterizations are performed in children annually. More than 40% are interventional procedures with more than 50% of these interventions performed in infancy. In the past three years, five new percutaneous intervention methods have been introduced: stent insertion in native coarctation and in recoarctation, stent insertion in stenosis of the pulmonary branches, percutaneous valve insertion in the pulmonary position, dilatation of the existing stent, and closure of aortopulmonary collaterals in children with a univentricular heart. The steps were made by the continuous efforts of team members with support, mentoring, and continuous cooperation with foreign experts from three foreign institutions (DeutschesHerzZentrum Muenchen, KinderherzZentrum Linz, KidsHeart- Center Budapest). Conclusion: Our center stands alongside the rare centers in Europe that can perform the abovementioned procedures. The activities resulted in the improvement of the quality of care and form the basis for further development of the profession within the framework of our country