Анестезия для пациента с болезнью Вильсона. Клинический случай

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu“, Spitalul Clinic Republican, Conferința naţională de gastroenterologie şi hepatologie cu participare internaţională ”Actualităţi în gastroenterologie şi hepatologie” 16 iunie 2016 Chișinău, Republica MoldovaWilson’s disease is a clinical biologically entity related to disorders of copper metabolism, affecting biliary excretion, with accumulation mostly in the liver and other tissues and organs (nervous system, cornea, kidneys, heart, skeletal system), pathogenetic subsequent expression of a genetic defect with autosomal recessive transmission. There are very limited reports of administration of anesthesia in patients with Wilson’s disease, only cases of regional anesthesia for limb surgery and general anesthesia for tooth extraction Болезнь Вильсона является клинико-биологическим состоянием, обусл овл енным расстройством метаболизма меди с нарушением желчной экскреции с последующим накоплением в печени и в других тканях и органах (нервной системе, роговице, почках, сердце, скелетной системе), выражением генетического дефекта, переданного аутосомно-рецессивно. Есть очень мало сведений о введении анестезии у пациентов с болезнью Вильсона, в частности случаи региональной анестезии для хирургии конечностей и общей анестезии для удаления зуба

Патофизиология синдрома MODS после трансплантации печени

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu“, IMSP Spitalul Clinic Republican, Conferința naţională de gastroenterologie şi hepatologie cu participare internaţională ”Actualităţi în gastroenterologie şi hepatologie” 16 iunie 2016 Chișinău, Republica MoldovaMODS (multiple organ dysfunction syndrome) can develop in the postoperative period in patients with liver transplantation and drastically reduces the survival rate of recipients. Triggers involved in the occurrence of MODS (sepsis, shock of various etiologies, extracorporeal circulation, multiply transfused, large surgery, etc.) elicits a humoral and cell reply from the body. The clinical consequence of this humoral and cellular answer is a continuous process, constantly changing, including SIRS, CARS and MARS, which endangers the patient’s life. During the years 2013–2016 in Moldova were performed 19 surgeries for liver transplantation, which were included in the study, divided into two groups: the fi rst group – 7 patients who met criteria MODS, lot 2 – 12 without MODS criteria. Among the primary pathological aggression that could cause severe development in MODS were recorded: a) the preoperative porto-pulmonary syndrome in 2 patients, CID syndrome – 3 patients, cholestatic syndrome and severe hepatodepressive – 7 patients; b) intraoperative – massive haemorrhage in one patient; c) postoperative – massive hemorrhage 4, relaparatomie – 2, CID syndrome – 4, acute rejection – three recipient. In conclusion, the survival of recipients is largely influenced by the development of MODS syndrome in the postoperative period of liver transplantation.Синдром MODS, который может развиваться в послеоперационном периоде у больных с трансплантацией печени, является опасным осложнением, потому что резко может снижать выживаемость реципиентов. Триггеры возникновения MODS (сепсис, шок различной этиологии, искусственное кровообращение, многократные переливания, большая хирургия и т.д.) вызывают гуморальный и клеточный ответ организма. Этот гуморальный и клеточный ответ образуют непрерывный процесс, постоянно меняющийся, в том числе СИРС, КАРС и МАРС, которые ставят под угрозу жизнь пациента. За 2013-2016 годы в Молдове были проведены 19 операций по пересадке печени, которые были включены в исследование и разделены на две группы: первая группа – 7 больных, которые соответствовали критериям MODS, вторая группа – 12 пациентов без критериев MODS. Среди первичных патологических агрессий, которые могут привести к серьезному развитию MODS, были записаны: а) предоперационное – порто-легочный синдром у 2 больных, синдром ДВС – 3 пациента, холестатический синдром – 7; b) интраоперационной – массивное кровоизлияние у одного пациента; c) послеоперационной – массивное 1086кровоизлияние – 4, реоперация – 2, синдром ДВС – 4, острое отторжение – у трех реципиента. В заключение отметим, что выживание получателей во многом зависит от развития синдрома MODS в послеоперационном периоде после трансплантации печени

Anesthetic and intensive care management in a transoral surgical approach of a patient with atlantoaxial dislocation

Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, Clinical Republican Hospital, Department of Anesthesiology and Intensive Care, Clinical Republican Hospital, Department of NeurosurgeryBackground. Transoral approach is an advanced neurosurgical technique in the treatment of atlantoaxial dislocation with spinal cord compression. Good cooperation between the surgical and the anesthetic teams during the treatment of this pathology plays a key role in achieving a positive result

Дисфункция трансплантата печени, вызванная вирусной инфекцией COVID-19, клинический случай

Rezumat. La pacienții cu infecția virală COVID-19, leziunile hepatocelulare atestă 14-53% cazuri, rareori cu dezvoltarea hepatitelor acute. Pacienții cu COVID-19 și citoliză >5 N prezintă risc crescut de deces cu dezvoltarea infecțiilor, disfuncției imune preexistente. Material și metode: Femeie 52 ani, cu ciroză hepatica (CH) VHD, MELD Na 21, transplantată cu hemificat LD, cu donator viu. In ziua 14 post-TH dezvoltă infecție virală SARS CoV2. Rezultate: Se atestă creșterea semnificativă ale enzimelor hepatice din ziua 14 post TH, diareie (Ag. Cl. Difficile - pozitiv, inițiat tratament corespunzător). Evolutia bolii cu agravare continuă prin citoliză marcată (>20N), creșterea markerilor de inflamație, prezența infiltratiei pulmonare hilo-bazale, revarsat pleural pe dreapta. Tratamentul efectuat în funcție de culturile primite, imunosupresia (tacrolimus) menținută la nivel suboptim. Saturația păstrată pe parcursul infecției. Enzimele hepatice stagnante, cu scăderea treptată din ziua 27. După 39 zile de la debut, starea clinico-biochimică ameliorată, tacrolimus ajustat conform protocolului, reluat MMF. Concluzii: Factorii care au influențat evoluția grefei hepatice: patologia hepatica pre-existentă, hiponatriemie, infecția virală SARS COV 2, infecția Cl. Difficile, dereglările hemodinamice vasculare, complicațiile biliare, durata prelungită în unitatea de terapie intensivă, perioada de spitalizare îndelungată, complicațiile biliare. Tratamentul imunosupresor asociat infecției cu SARS COV 2 necesită monitorizat, echilibrat în funcție de starea clinico-biologică a pacientului, ținînd cont de doză, tipul de imunosupresie, perioada post TH.Summary. In patients with the viral infection COVID-19, hepatocellular lesions could be found in 14-53% of cases, rarely with the development of acute hepatitis. Patients with COVID-19 and cytolysis >5 N have an increased risk of death with the development of infections, pre-existing immune dysfunction. Material and methods: Female 52 years old, with liver cirrhosis (LC) HDV, MELD Na 21, Living donor liver transplantation (LDLT). On day 14 post-LT develops SARS CoV2 viral infection. Results: A significant increase in liver enzymes from day 14 post LT, diarrhea (Ag. Cl. Difficile - positive, initiated treatment resulted). The evolution of the aggravating disease continues with marked cytolysis, the increase of inflammatory indices, with the development of hilo-basal pulmonary infiltration with pleural effusion on the right. Treatment performed according to the cultures received, immunosuppression (tacrolimus) maintained at a suboptimal level. Saturation kept during the infection period. Stagnant liver enzymes, gradual decrease from day 27. After 39 days from onset, clinical-biochemical status improved, tacrolimus adjusted according to protocol, MMF resumed. Conclusions: The factors that influenced the evolution of the liver transplant: pre-existing liver disease, hiponatriemia, SARS COV 2 viral infection, C. difficile infection, vascular hemodynamic disorders, biliary complications, prolonged duration in the intensive care unit, long hospital stay. The immunosuppressive treatment associated with SARS COV 2 infection needs to be monitored, balanced according to the clinical-biological state of the patient, taking into account the dose, and type of immunosuppression, the post-LT period.Резюме. У больных вирусной инфекцией COVID-19 гепатоцеллюлярное поражение наблюдается в 14-53% случаев, иногда с развитием острого гепатита. Пациенты с COVID-19 и цитолизом >5 N имеют повышенный риск смертности с развитием инфекций, ранее существующей иммунной дисфункцией. Материал и методы: Женщина 52 лет, с циррозом печени (ЦП) HDV, MELD Na 21, трансплантирована от живого донора (LDLT). На 14-е сутки после ТП выявлено развитие вирусной инфекции SARS CoV2. Результаты: Наблюдается значительное повышение активности печеночных ферментов с 14-го дня после ТП, диарея (Ag. Cl. Difficile - положительный результат, начато лечение согласно протоколу). В ходе лечения продолжается негативная динамика: цитолиз > 20N, значительное повышение маркеров воспаления, с развитием хило-базальной воспалительной инфильтрацией легких, с плевральным выпотом справа. Сатурация сохранялась на уровне весь период инфекции. Лечение проведено согласно полученных культур, иммуносупрессия (такролимус) поддерживается на субоптимальном уровне. Застой печеночных ферментов, постепенное снижение с 27-го дня. Через 39 дней от начала заболевания улучшился клинико-биохимический статус, такролимус откорректирован согласно протоколу, возобновлен ММФ. Выводы: Факторы, повлиявшие на эволюцию донорского транспланта печени: изначальная патология печени, гипонатриемия, вирусная инфекция SARS COV 2, Cl Difficile, нарушение гемодинамики, гепато-билиарные осложнеия, длительное пребывание в отделении интенсивной терапии, длительное пребывание в стационаре, гепатобилиарные осожнения. Иммуносупрессивное лечение, сочетанное с инфекцией SARS COV 2, необходимо мониторизировать, взвешивать по клинико-биологическому состоянию больного с учетом дозы, вида иммуносупрессии, периода пост-ТП

The role of ferritin in determining the severity of critical patients with COVID-19 admitted in Intensive Care Units

Catedra de anesteziologie şi reanimatologie nr. 2, Universitatea de Stat de Medicină şi Farmacie ”Nicolae Testemiţanu”, Chişinău, Republica Moldova, Spitalul Clinic Republican, Chişinău, Republica MoldovaRezumat Introducere. Pandemia de Coronavirus 2019 (COVID-19), cauza sindromului respirator acut sever coronavirus 2019 (SARS-CoV-2) indus, continuă să reprezinte o ameninţare uriaşă pentru sănătatea publică mondială. Există dovezi că feritina este un marker-cheie în determinarea afectării celulare, dar rolul său potenţial în infecţia cu Coronavirus 2019 (COVID-19) nu este elucidat suficient. Scopul nostru a fost să evaluăm dacă hiperferitinemia poate fi un marker al prognosticului negativ la pacienţii gravi cu infecţie COVID-19. Material şi metode. Studiul a inclus 106 pacienţi adulţi, de ambele genuri, cu vârsta cuprinsă între 29 şi 88 de ani (vârsta medie 63,6±12,6 ani), diagnosticaţi cu COVID-19. Nivelurile de feritină serică au fost măsurate la momentul diagnosticului, folosind tehnica de chemiluminiscenţă. Monitoringul pacienţilor a inclus: evaluarea statutului neurologic (oximetria cerebrală, gradul de afectare a cunoştinţei, alte semne clinice şi paraclinice), sistemul respirator (SpO2 , FiO2 , indicele oxigenării, bucla respiratorie, radiografia cutiei toracice, CT pulmonar etc.), statutul hemodinamic (PiCCO, monitorizarea invazivă şi non-invazivă, ECG, ECO Dopller), echilibrele gazos, acido-bazic şi electrolitic, analize biologice ale sângelui (ureea, creatinina, glicemia, coagulograma, ALT, AST, bilirubina), analiza generală a urinei etc., proteina C reactivă, lactat dehidrogenaza, acidul lactic şi feritina serică. Rezultate. Feritina serică a avut valori crescute la 102 (96,23%) pacienţi. Din cei 17 bolnavi care aveau ferititina serică la valori moderate, ARDS faza I s-a înregistrat la 10 (52,82%) pacienţi, ARDS faza II – la 5 (52,82%) şi ARDS faza III – la 2 (11,77%) bolnavi. La pacienţii cu valorile feritinei severe, ARDS faza I s-a constatat la 19 (43,18%) pacienţi, ARDS faza II şi III – la câte 16 (31,37%) bolnavi. La bolnavii cu valorile feritinei critice, ARDS faza I nu s-a înregistrat, ARDS faza II a fost determinat la 14 (41,18%) şi faza III – la 20 (51,82%) de bolnavi. La cei 15 pacienţi monitorizaţi prin PiCOO, a fot stabilită creşterea indicelui ELWI de 2-3 ori. La un ELWI peste 18 ml/kg nu au fost supravieţuitori. Menţionăm că la cei decedaţi, valorile feritinei serice au avut un nivel critic. Concluzii. Feritina serică este un marker important în determinarea severităţii şi a riscului crescut de dezvoltare a MODS-ului la pacienţii cu COVID-19.Abstract Introduction. The pandemic of Coronavirus 2019 disease, the cause of severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2) induced, continues to pose a huge threat to global public health. There is evidence that ferritin is a key marker in determining cell damage, but its potential role in COVID-19 infection is not sufficiently elucidated. Our aim was to evaluate whether hyper ferritinemia may be a marker of the negative prognosis in severe patients with COVID-19 infection. Material and methods. The study included 106 adult patients, aged 29 and 88 years (mean age 63.6±12.6 years), diagnosed with COVID-19. Serum ferritin levels were measured at the time of diagnosis using a chemiluminescence technique. Patient monitoring included: assessment of neurological status (brain oximetry, knowledge impairment, other clinical and paraclinical signs), respiratory system (SpO2 , FiO2 , respiratory rate, oxygenation index, respiratory loop, chest x-ray, pulmonary CT etc.), hemodynamic status (PiCCO, invasive and noninvasive monitoring, ECG, echo-Doppler), gas, acid-base and electrolyte balances, biological blood tests (urea, creatinine, blood glucose, coagulation tests, ALT, AST, bilirubin), general urinalysis, C-reactive protein, lactate dehydrogenase, lactic acid and serum ferritin. Results. Serum ferritin had increased values in 102 (96.23%). In 17 patients with moderate ferritin values, phase I ARDS was recorded in 10 (52.82%), phase II ARDS in 5 (52.82%) and phase III ARDS in 2 (11.77%) patients. In patients with severe ferritin values, phase I ARDS was found in 19 (43.18%), phase II and III ARDS in 16 (31.37%) patients. In patients with critical ferritin values, phase I ARDS was not recorded, phase II ARDS was determined in 14 (41.18%) and phase III in 20 (51.82%) patients. In the 15 patients monitored by PiCCO, we determined the increase of the ELWI index for 2-3 times. At ELWI values over 18 ml/kg, there were no survivors. We mention that in those who died, the ferritin had a critical level. Conclusions. Serum ferritin is an important marker in determining the severity and increased risk of developing MODS in patients with COVID-19

Sindromul disfuncției multiple de organe: consecință a chirurgiei cardiace pediatrice

Department of Anesthesiology and Reanimatology No 2 Nicolae Testemitsanu State University of Medicine and Pharmacy, Chisinau, the Republic of Moldova, Republican Clinic Hospital, Department of Anesthesiology and Intensive Therapy, The 5th International Congress of the Society of Anesthesiology and Reanimatology of the Republic of Moldova, 16th Edition of the International Course of Guidelines and Protocols in Anesthesia, Intensive Care and Emergency Medicine, 28th Meeting of the European Society for Computing and Technology in Anesthesia and Intensive Care September 27-29, 2018, Chisinau, the Republic of MoldovaBackground: There are a number of pathophysiologic processes that may result in the multiple organ dysfunction syndrome (MODS) in children. Despite the scientific, technological and surgical improvements of the elective pediatric cardiac surgery utilizing cardiopulmonary bypass, it continues to account for increased complications, the potential for MODS. Objective: Estimating the risk factors for multiple organ dysfunction syndrome in children after the cardiopulmonary bypass and particularities of organ dysfunction in this population. Material and methods: We selected 203 children who underwent open heart surgery, during 2010-2012, divided them into 2 groups: group 1 included 47 children that included criteria for multiple organ failure by Goldstein and group 2, patients who did not develop MODS. Results: Patients diagnosed with MODS presented lower mean age (36,1±12,0 vs 54,5±8,0 months, p < 0.012), lower weight (12,5±2,7 vs 17,9±2.0 kg, p < 0.007), and longer cardiopulmonary bypass duration (108,3±17,4 vs 54,1±4,7 minutes p<0,0001). The duration of intensive care unit stay (6,5±2,3 vs 2.1±0,2 days p<0,0001) was significantly increased in patients from MODS group. Conclusions: The clinical criteria adopted have allowed the identification of risk group for MODS, which presented lower weight and longer CPB duration as predisponent factors. Patients with MODS remain in ICU and in hospitalization for a longer period of time. The MODS prevalence in our group is 23.1%, in contrast to the percentage reported in other studies that has been between 10.9% and 27.2%. The most common types of dysfunction were those of the cardiovascular, respiratory and renal system.Introducere: Există o serie de procese patofiziologice care pot determina sindromul de disfuncție multiplă de organe (MODS) la copii. Deşi chirurgia cardiacă pediatrică a cunoscut o dezvoltare ştiinţifică şi tehnologică semnificativă, utilizând circulația extracorporeală, acest tip de intervenţii continuă să prezinte complicații majore, cu potențial de dezvoltare a MODS. Obiectiv: Estimarea factorilor de risc de dezvoltare a MODS la copiii operați pe cord în condiții de circulație extracorporeală. Materiale şi metode: În studiu au fost incluşi 203 copii operați pe cord, în perioada 2010-2012, lotul 1 - 47 copii care au întrunit criteriile MODS după Goldstein, lotul 2 - pacienții care nu au dezvoltat MODS. Rezultate: Pacienții diagnosticați cu MODS aveau o vârstă medie mai mică (36,1 ± 12,0 vs 54,5 ± 8,0 luni, p <0,012), greutate mai mică (12,5 ± 2,7 vs 17,9 ± 2,0 kg, p <0,007) și o durată mai lungă de CEC (108,3 ± 17,4 vs 54,1 ± 4,7 minute p <0,0001). Durata spitalizării în UTI a fost semnificativ mai mare în cazul pacienților din grupul MODS (6,5 ± 2,3 vs 2,1 ± 0,2 zile p <0,0001). Concluzii: Criteriile clinice adoptate au permis identificarea grupului de risc pentru MODS, care a prezentat o greutate mai mică și o durată mai lungă a CEC ca factori predispozanți. Pacienții cu MODS rămân în UTI pentru o perioadă mai lungă de timp. Prevalența MODS în grupul nostru este de 23,1%, în contrast cu alte studii care au cuprins între 10,9% și 27,2%. Cele mai frecvente tipuri de disfuncții au fost ale sistemului cardiovascular, respirator și renal