Učinak inhalacijskih anestetika na akutno oštećenje bubrega

Acute kidney injury (AKI) is a serious complication associated with increased morbidity and mortality. Total incidence of AKI in hospitalized patients is 1%-5%. As many as 30% of these patients develop AKI in the perioperative period, which is associated with anesthesia and surgery. Despite scientific advances and improved surgery techniques, as well as treatment in intensive care units, no significant decrease in AKI incidence has been achieved. To change this outcome, it is important to identify patients at risk of AKI and prevent its occurrence. Correct selection of anesthetic drugs during general anesthesia, adjusted to the individual needs of patients, also influences the overall outcome of treatment. Nowadays, inhalational anesthetics are not considered nephrotoxic. The more so, inhalational anesthetics have a strong and direct protective effect on many organs through preconditioning and postconditioning. New studies have shown that sevoflurane diminishes ischemia/reperfusion kidney injury and has an anti-inflammatory effect, thus having the potential to reduce the occurrence of AKI. Given the incidence of AKI in the perioperative period, as well as new findings about anesthetics, the issue of anesthetic selection during general anesthesia might be of crucial importance for the final outcome of treatment.Akutno oštećenje bubrega (AOB) je ozbiljna komplikacija povezana s povišenim pobolom i smrtnošću. Ukupna incidencija AOB u bolničkih bolesnika iznosi 1%-5%. Čak 30% tih bolesnika su razvili AOB u perioperacijskom razdoblju kao posljedicu anestezije i operacije. Unatoč novim znanstvenim spoznajama i unaprjeđenju kirurških tehnika te liječenja u jedinicama intenzivne njege, nije postignut značajniji pomak u smanjenju incidencije AOB. Za promjenu tog ishoda važno je prepoznavanje rizične skupine bolesnika te prevencija. Na ukupni ishod liječenja utječe i pravilan odabir anestetičkih sredstava tijekom opće anestezije, koji je najbolje prilagođen individualnim potrebama bolesnika. Danas se smatra da inhalacijski anestetici nisu nefrotoksični. Dapače, inhalacijski anestetici imaju snažan izravan zaštitni učinak na mnoge organe kroz predkondicioniranje i postkondicioniranje. Nova istraživanja pokazuju da sevofluran smanjuje ishemijsko-reperfuzijsku ozljedu bubrega i djeluje protuupalno, zbog čega ima potencijal smanjiti pojavu AOB. S obzirom na incidenciju AOB u perioperacijskom razdoblju i nove spoznaje o anesteticima, pitanje odabira anestetika tijekom opće anestezije moglo bi biti od ključnog značenja za sveukupni ishod liječenja

PREOPERATIVE NUTRITION IN SURGICAL PATIENTS

Preoperacijsko gladovanje, „nihil per os“ (ništa na usta) od ponoći na dan operacije je nepotrebno i može dovesti do različitih komplikacija te se smatra opsoletnim. Smjernice preporučuju uzimanje tekućine do 2 sata prije uvoda u anesteziju bez straha od aspiracije ili drugih neželjenih učinaka. Gladovanje zajedno s operacijom, koja je stres za organizam, dovodi do kataboličkog stanja organizma, produžuje oporavak bolesnika te uzrokuje brojne druge postoperacijske komplikacije. Ciljevi preoperacijske prehrane su izbjegavanje gladovanja kako bi se održao proteinski status, održavanje imunološke, mišićne i endokrinološke funkcije, te ubrzanje oporavka nakon operacije. Velik broj bolesnika je pri dolasku u bolnicu pothranjen. Nadalje, pothranjenost je nezavisni rizik za povećani mortalitet, morbiditet te dužinu boravka u bolnici. Stoga preoperacijski probir i procjena nutritivnog stanja te adekvatna preoperacijska prehrana trebaju postati obvezni kod kirurških bolesnika. Smjernice Europskog društva za kliničku prehranu i metabolizam (ESPEN) nalažu primjenu preoperacijske prehrane kod teško pothranjenih bolesnika čak i ako se operacija zbog toga mora odgoditi. Brojna istraživanja su dokazala dobrobit reoperacijske prehrane za bolesnikovo opće stanje, smanjenje postoperacijskih komplikacija te sigurnu upotrebu bez straha od aspiracije i drugih komplikacija. ESPEN smjernice preporučuju preoperacijsku primjenu ugljikohidratnih pripravaka te daju prednost imunonutriciji nad običnim enteralnim pripravcima. U zaključku možemo reći da bi preoperacijska prehrana kirurških bolesnika trebala postati standardni dio protokola kod pripreme bolesnika za operaciju.Preoperative fasting, nihil per os after midnight on the day of surgery is considered unnecessary and obsolete. Guidelines encourage taking clear fl uid up to 2 hours before surgery, without fear of aspiration and other complications. Fasting together with surgery, which represents stress for the body, leads to catabolic state, prolongs patient recovery, and causes postoperative complications. The aim of preoperative nutrition and avoiding fasting is to maintain protein balance, muscle and immune function, and to facilitate postoperative recovery. On admission to the hospital, most patients are malnourished, including even 40% of patients undergoing gastrointestinal surgery. Preoperative malnutrition is an independent risk factor for postoperative complications and prolonged length of stay in the hospital. Preoperative screening, assessment of nutritional status, and appropriate preoperative nutrition are mandatory in surgical patients. According to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines, in severely malnourished surgical patients, preoperative nutritional support should be used even if the operation must be delayed. Numerous studies have demonstrated favorable impact of preoperative nutrition, posing no risk of aspiration and other complications. ESPEN guidelines recommend preoperative use of carbohydrate and immunonutrients. Preoperative nutrition should become standard part of the care protocol for surgical patients

Effect of inhalational anesthetics on acute kidney injury

Acute kidney injury (AKI) is a serious complication associated with increased morbidity and mortality. Total incidence of AKI in hospitalized patients is 1%-5%. As many as 30% of these patients develop AKI in the perioperative period, which is associated with anesthesia and surgery. Despite scientific advances and improved surgery techniques, as well as treatment in intensive care units, no significant decrease in AKI incidence has been achieved. To change this outcome, it is important to identify patients at risk of AKI and prevent its occurrence. Correct selection of anesthetic drugs during general anesthesia, adjusted to the individual needs of patients, also influences the overall outcome of treatment. Nowadays, inhalational anesthetics are not considered nephrotoxic. The more so, inhalational anesthetics have a strong and direct protective effect on many organs through preconditioning and postconditioning. New studies have shown that sevoflurane diminishes ischemia/reperfusion kidney injury and has an anti-inflammatory effect, thus having the potential to reduce the occurrence of AKI. Given the incidence of AKI in the perioperative period, as well as new findings about anesthetics, the issue of anesthetic selection during general anesthesia might be of crucial importance for the final outcome of treatment

Predictors of homelessness among vulnerably housed adults in 3 Canadian cities: a prospective cohort study

Abstract Background Homelessness is a major concern in many urban communities across North America. Since vulnerably housed individuals are at risk of experiencing homelessness, it is important to identify predictive factors linked to subsequent homelessness in this population. The objectives of this study were to determine the probability of experiencing homelessness among vulnerably housed adults over three years and factors associated with higher risk of homelessness. Methods Vulnerably housed adults were recruited in three Canadian cities. Data on demographic characteristics, chronic health conditions, and drug use problems were collected through structured interviews. Housing history was obtained at baseline and annual follow-up interviews. Generalized estimating equations were used to characterize associations between candidate predictors and subsequent experiences of homelessness during each follow-up year. Results Among 561 participants, the prevalence of homelessness was 29.2 % over three years. Male gender (AOR = 1.59, 95 % CI: 1.14–2.21) and severe drug use problems (AOR = 1.98, 95 % CI: 1.22–3.20) were independently associated with experiencing homelessness during the follow-up period. Having ≥3 chronic conditions (AOR = 0.55, 95 % CI: 0.33–0.94) and reporting higher housing quality (AOR = 0.99, 95 % CI: 0.97–1.00) were protective against homelessness. Conclusions Vulnerably housed individuals are at high risk for experiencing homelessness. The study has public health implications, highlighting the need for enhanced access to addiction treatment and improved housing quality for this population

Predictors of homelessness among vulnerably housed adults in 3 Canadian cities: a prospective cohort study

Background: Homelessness is a major concern in many urban communities across North America. Since vulnerably housed individuals are at risk of experiencing homelessness, it is important to identify predictive factors linked to subsequent homelessness in this population. The objectives of this study were to determine the probability of experiencing homelessness among vulnerably housed adults over three years and factors associated with higher risk of homelessness. Methods: Vulnerably housed adults were recruited in three Canadian cities. Data on demographic characteristics, chronic health conditions, and drug use problems were collected through structured interviews. Housing history was obtained at baseline and annual follow-up interviews. Generalized estimating equations were used to characterize associations between candidate predictors and subsequent experiences of homelessness during each follow-up year. Results: Among 561 participants, the prevalence of homelessness was 29.2 % over three years. Male gender (AOR = 1.59, 95 % CI: 1.14–2.21) and severe drug use problems (AOR = 1.98, 95 % CI: 1.22–3.20) were independently associated with experiencing homelessness during the follow-up period. Having ≥3 chronic conditions (AOR = 0.55, 95 % CI: 0.33–0.94) and reporting higher housing quality (AOR = 0.99, 95 % CI: 0.97–1.00) were protective against homelessness. Conclusions: Vulnerably housed individuals are at high risk for experiencing homelessness. The study has public health implications, highlighting the need for enhanced access to addiction treatment and improved housing quality for this population.Medicine, Faculty ofOther UBCNon UBCGeneral Internal Medicine, Division ofMedicine, Department ofReviewedFacult