Učinak hemodilucije na bubrežnu funkciju nakon izloženosti izvantjelesnom krvotoku [Effects of hemodilution on renal function after exposure of cardiopulmonary bypass]

Nowadays still a great number of heart surgeries is usually carried out with the use of the system of cardiopulmonary bypass. The system replaces the function of heart and lungs during the surgery which enables it. The technique of the system for cardiopulmonary bypass is nowdays very modern and to a great extent is adapted to physilogical functions of our organism. Despite that cardiopulmonary bypass has unwanted effects on some physiological functions of our organism. One of the negative physiological effects of cardiopulmonary bypass is a possible kidney damage. The frequency of kidney failure which happens after a surgery with the use of cardiopulmonary bypass is a possible kidney damage. The frequency of acute kidney failure which happens after heart surgeries with the use of cardiopulmonary bypass is about 1-5 %. The frequency of subclinical kidney damage is bigger and by routine traditional clinical tests it can hardly be proved in earlier stages. The traditional tests, the so called tests for diagnostic kidney damage, are serumal urea and the clearance of creatinine from urine and the analysis of the sediments of urine. Initial tubulo-interstitial changes are discovered with graet difficulty. However, they can be discovered in greater damages. Subclinical kidney damage, especially kidney tubules, can be proved in early indicators of kidney damage. The two mentioned indicators are highly specific early indicators of the damage of kidney tubules – the protein of law molecular mass alpha-1- microglobulin (A1M) and lipocalin associated with neutrophil gelatinase (NGAL) which are determined in urine. This paper primarily studied unwanted effects of cardiopulmonary bypass upon kidney damage, that is to say, the function of proximal tubules of kidneys and the influence and role of hemodilution on renal function caused by „priming“ solution. In order to define kidney damage, early indicators of damaged kidney proximal tubules NGAL and A1M were determined in urine and for the sake of comparison they were determined in serum as well as traditional tests of urea and creatinine. This research showed the results of a prospective study which included 158 subjects who were subjected to elective heart surgeries with the use of cardiopulmonary bypass. The influence of hemodilution was observed in two groups. The first group of subjects with mild hemodilution was defined as the one where the ratio of hematocrits after a surgery in comparison with hematocrits during the surgery was greater than 60%. The second group of subjects with moderate hemodilution was the group where the ratio of hematocrits after the surgery in comparison with hematocrits during the surgery was less than 60 %. This research shows that moderate hemodilution during heart surgeries accompanied by cardiopulmonary bypass which is caused by diluted blood, the so called „priming solution“ of cardiopulmonary bypass, has an important effect upon the function of proximal kidney tubules. Early indicators of the damage of proximal kidney tubules A1M and NGAL in urine are very helpful and sensitive in proving disorders in early postoperative period of time after heart surgeries accompanied by cardiopulmonary bypass. The mentioned indicators have special values in observing dynamics during milder subclinical damages of proximal kidney tubules during cardiopulmonary bypass. A1M showed slightly greater sensitivity and increase of value than NGAL. The so called „classical“ indicators of kidney damage urea and creatinine in serum are not enough sensitive to prove early and subclinical kidney damage after heart surgeries accompanied by cardiopulmonary bypass. The study did not show, that in subjects with preoperative normal kidney function, transfusion treatment has a negative effect on the function of proximal kidney tubules during 24 hours after a heart surgery accompanied by cardiopulmonary bypass. The results of the study show that the length of cardiopulmonary bypass singificantly infleunces the damage of kidney function

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

Ceftazidime/ Avibactam for Treatment of Intrahospital Ventilator-Associated Pneumonia in COVID-19 Patients

U razdoblju pandemije koronavirusne bolesti 2019. (COVID-19) mnogi bolesnici kojima je bila potrebna invazivna mehanička ventilacija, primljeni su u jedinice intenzivnog liječenja (JIL) zbog teškog respiratornog zatajenja povezanog s bolešću COVID-19. Prijam u JIL i invazivna mehanička ventilacija neovisni su rizici za pneumoniju povezanu s ventilatorom (engl. ventilator associated pneumonia; VAP), kod koje je zabilježena visoka stopa smrtnosti i dulji boravak u JIL-u te je produljeno bolničko liječenje. Ako govorimo o uzročnicima VAP-a, Pseudomonas aeruginosa bio je jedan od glavnih gram-negativnih nefermentirajućih uzročnika ove patologije, zajedno s Burkholderia cepacia i Stenotrophomonas maltophilia u manjoj mjeri. Protiv gram-negativnih mikroorganizama otpornih na karbapeneme, ceftazidim/avibaktam (CZA) jedan je od najčešće korištenih antimikrobnih lijekova. Cilj ovog preglednog članka bio je opisati korištenje CZA u liječenju bolesnika s infekcijom COVID-19 koji su razvili VAP uzrokovan P. aeruginosa, B. cepacia i S. maltophilia, usporediti to s podatcima objavljenim u literaturi te skrenuti pozornost na kontinuiranu primjenu lijeka kao drugačijeg modaliteta u odnosu na standardni način primjene u bolusu. Unatoč visokoj smrtnosti kritično oboljelih bolesnika s COVID-om, CZA predstavlja valjanu opciju liječenja VAP-a uzrokovanog nefermentirajućim gram-negativnim mikroorganizmima.In the period of the coronavirus diseFase 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to the intensive care unit (ICU) due to severe respiratory failure associated with COVID-19 infection. In fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with a high mortality rate and longer ICU and hospital stays. Pseudomonas aeruginosa was the first causative agent of this pathology (VAP), but rare non-fermenting Gram-negative microorganisms such as Burkholderia cepacea and Stenotrophomonas maltophilia have also emerged as potential etiological agents. One of the most frequently used antibiotics against carbapenem- resistant Gram-negative microorganisms is ceftazidime/avibactam (CZA). The aim of this review article was to describe the use of CZA in a series of cases of patients with COVID-19 infection who developed difficult-to-treat VAP due to P. aeruginosa, B. cepacea and S. maltophilia and to compare it with data published in the literature, as well as to draw attention to the continuous administration of the drug as a different modality compared to the standard method of bolus administration. Despite the high mortality of critically ill patients with COVID-19, CZA, especially in combination therapy, could represent a valid treatment option for VAP caused by non-fermenting Gram-negative microorganisms

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

Effects of hemodilution on renal function after exposure of cardiopulmonary bypass

Danas se još uvijek velik broj rutinskih srčanih operacija uobičajeno izvodi uz uporabu sustava za izvantjelesni krvotok. Sustav zamjenjuje funkciju srca i pluća tijekom samog operacijskog zahvata što omogućava izvođenje operacijskog zahvata. Tehnika sustava za izvantjelesni krvotok danas je već jako napredna i u velikoj mjeri prilagođena fiziološkim funkcijama ljudskog tijela. Unatoč tome izvantjelesni krvotok ima i neželjene učinke na stanovite fiziološke funkcije organizma, a jedan od negativnih fizioloških učinaka izvantjelesnog krvotoka je moguće bubrežno oštećenje. Učestalost akutnog bubrežnog zatajenja koje se događa iza srčanih operacija uz uporabu izvantjelesnog krvotoka iznosi oko 1-5%. Učestalost subkliničkog bubrežnog oštećenja je veća, a primjenom uobičajenih kliničkih ispitivanja (ureja, kreatinin) teško se može dokazati u ranoj fazi liječenja. Tradicionalni su tzv. testovi za dijagnostiku oštećenja bubrega i to: serumska urea i kreatinin, klirens kreatinina iz urina te analiza sedimenta urina. Tim se i takvim laboratorijskim ispitivanjima teško otkrivaju početne tubulointersticijske promjene, a mogu se otkriti tek u poodmaklim jačim oštećenjima. Subkliničko bubrežno oštećenje, posebice bubrežnih tubula, može se dokazati ranim pokazateljima bubrežnog oštećenja. Dvoje od pokazatelja su visoko specifični rani pokazatelji oštećenja proksimalnih bubrežnih tubula. To su proteini niske molekulske mase alfa-1-mikroglobulin (A1M) i lipokalin udružen s neutrofilnom želatinazom (NGAL) koji se određuju u urinu i čija razina sadržaja ima značajnu dijagnostičku vrijednost. U ovome se znanstveno-istraživačkom radu prvenstveno promatrao neželjeni učinak izvantjelesnog krvotoka na oštećenje bubrega, tj. na funkciju proksimalnih tubula bubrega te utjecaj i uloga hemodilucije nastale „priming“ otopinom. Za definiranje bubrežnog oštećenja određivani su u urinu rani pokazatelji oštećenja bubrežnih tubula NGAL i A1M, a radi usporedbe vrijednosti i korisnosti određivani su u serumu i uobičsjene tvari urea i kreatinin. U ovom su istraživanju prikazani rezultati prospektivne opažajne studije u koju je uključeno 158 ispitanika podvrgnutih planiranim srčanim operacijama uz uporabu izvantjelesnog krvotoka. Promatrao se uticaj hemodilucije u dvije skupine ispitanika. Skupina ispitanika s blagom hemodilucijom definirana je kao ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije veći od 60%, a skupina s umjerenom hemodilucijom je ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije manji od 60%. Iz rezultata ovog istraživanja može se zaključiti da umjerena hemodilucija tijekom srčanih operacijskih zahvata uz izvantjelesni krvotok koja nastaje razrjeđenjem krvi tzv. „priming“ otopinom izvantjelesnog krvotoka ima zaštitni učinak na funkciju proksimalnih bubrežnih tubula. Rani pokazatelji oštećenja proksimalnih bubrežnih tubula A1M i NGAL u urinu vrlo su korisni i osjetljivi za dokazivanje poremećaja u ranom poslijeoperacijskom vremenu nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. Navedeni pokazatelji imaju posebnu vrijednost u praćenju dinamike pri blažim subkliničkim oštećenjima proksimalnih bubrežnih tubula tijekom izvantjelesnog krvotoka. A1M je pokazao nešto veću osjetljivost i porast vrijednosti od NGAL. Tzv. „klasični“ pokazatelji bubrežnog oštećenja ureja i kreatinin u serumu nisu dovoljno osjetljivi za dokazivanje ranog i subkliničkog bubrežnog oštećenja nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. U studiji se na ispitanicima s prijeoperacijski normalom bubrežnom funkcijom nije pokazalo da transfuzijsko liječenje negativno utječe na funkciju proksimalnih bubrežnih tubula u prva 24 sata nakon srčanog operacijskog zahvata uz izvantjelesni krvotok. Rezultati istraživanja vidljivo pokazuju da duljina izvantjelesnog krvotoka značajno utječe na oštećenje bubrežne funkcije.Nowadays still a great number of heart surgeries is usually carried out with the use of the system of cardiopulmonary bypass. The system replaces the function of heart and lungs during the surgery which enables it. The technique of the system for cardiopulmonary bypass is nowdays very modern and to a great extent is adapted to physilogical functions of our organism. Despite that cardiopulmonary bypass has unwanted effects on some physiological functions of our organism. One of the negative physiological effects of cardiopulmonary bypass is a possible kidney damage. The frequency of kidney failure which happens after a surgery with the use of cardiopulmonary bypass is a possible kidney damage. The frequency of acute kidney failure which happens after heart surgeries with the use of cardiopulmonary bypass is about 1-5 %. The frequency of subclinical kidney damage is bigger and by routine traditional clinical tests it can hardly be proved in earlier stages. The traditional tests, the so called tests for diagnostic kidney damage, are serumal urea and the clearance of creatinine from urine and the analysis of the sediments of urine. Initial tubulo-interstitial changes are discovered with graet difficulty. However, they can be discovered in greater damages. Subclinical kidney damage, especially kidney tubules, can be proved in early indicators of kidney damage. The two mentioned indicators are highly specific early indicators of the damage of kidney tubules – the protein of law molecular mass alpha-1- microglobulin (A1M) and lipocalin associated with neutrophil gelatinase (NGAL) which are determined in urine. This paper primarily studied unwanted effects of cardiopulmonary bypass upon kidney damage, that is to say, the function of proximal tubules of kidneys and the influence and role of hemodilution on renal function caused by „priming“ solution. In order to define kidney damage, early indicators of damaged kidney proximal tubules NGAL and A1M were determined in urine and for the sake of comparison they were determined in serum as well as traditional tests of urea and creatinine. This research showed the results of a prospective study which included 158 subjects who were subjected to elective heart surgeries with the use of cardiopulmonary bypass. The influence of hemodilution was observed in two groups. The first group of subjects with mild hemodilution was defined as the one where the ratio of hematocrits after a surgery in comparison with hematocrits during the surgery was greater than 60%. The second group of subjects with moderate hemodilution was the group where the ratio of hematocrits after the surgery in comparison with hematocrits during the surgery was less than 60 %. This research shows that moderate hemodilution during heart surgeries accompanied by cardiopulmonary bypass which is caused by diluted blood, the so called „priming solution“ of cardiopulmonary bypass, has an important effect upon the function of proximal kidney tubules. Early indicators of the damage of proximal kidney tubules A1M and NGAL in urine are very helpful and sensitive in proving disorders in early postoperative period of time after heart surgeries accompanied by cardiopulmonary bypass. The mentioned indicators have special values in observing dynamics during milder subclinical damages of proximal kidney tubules during cardiopulmonary bypass. A1M showed slightly greater sensitivity and increase of value than NGAL. The so called „classical“ indicators of kidney damage urea and creatinine in serum are not enough sensitive to prove early and subclinical kidney damage after heart surgeries accompanied by cardiopulmonary bypass. The study did not show, that in subjects with preoperative normal kidney function, transfusion treatment has a negative effect on the function of proximal kidney tubules during 24 hours after a heart surgery accompanied by cardiopulmonary bypass. The results of the study show that the length of cardiopulmonary bypass singificantly infleunces the damage of kidney function

Effects of hemodilution on renal function after exposure of cardiopulmonary bypass

Danas se još uvijek velik broj rutinskih srčanih operacija uobičajeno izvodi uz uporabu sustava za izvantjelesni krvotok. Sustav zamjenjuje funkciju srca i pluća tijekom samog operacijskog zahvata što omogućava izvođenje operacijskog zahvata. Tehnika sustava za izvantjelesni krvotok danas je već jako napredna i u velikoj mjeri prilagođena fiziološkim funkcijama ljudskog tijela. Unatoč tome izvantjelesni krvotok ima i neželjene učinke na stanovite fiziološke funkcije organizma, a jedan od negativnih fizioloških učinaka izvantjelesnog krvotoka je moguće bubrežno oštećenje. Učestalost akutnog bubrežnog zatajenja koje se događa iza srčanih operacija uz uporabu izvantjelesnog krvotoka iznosi oko 1-5%. Učestalost subkliničkog bubrežnog oštećenja je veća, a primjenom uobičajenih kliničkih ispitivanja (ureja, kreatinin) teško se može dokazati u ranoj fazi liječenja. Tradicionalni su tzv. testovi za dijagnostiku oštećenja bubrega i to: serumska urea i kreatinin, klirens kreatinina iz urina te analiza sedimenta urina. Tim se i takvim laboratorijskim ispitivanjima teško otkrivaju početne tubulointersticijske promjene, a mogu se otkriti tek u poodmaklim jačim oštećenjima. Subkliničko bubrežno oštećenje, posebice bubrežnih tubula, može se dokazati ranim pokazateljima bubrežnog oštećenja. Dvoje od pokazatelja su visoko specifični rani pokazatelji oštećenja proksimalnih bubrežnih tubula. To su proteini niske molekulske mase alfa-1-mikroglobulin (A1M) i lipokalin udružen s neutrofilnom želatinazom (NGAL) koji se određuju u urinu i čija razina sadržaja ima značajnu dijagnostičku vrijednost. U ovome se znanstveno-istraživačkom radu prvenstveno promatrao neželjeni učinak izvantjelesnog krvotoka na oštećenje bubrega, tj. na funkciju proksimalnih tubula bubrega te utjecaj i uloga hemodilucije nastale „priming“ otopinom. Za definiranje bubrežnog oštećenja određivani su u urinu rani pokazatelji oštećenja bubrežnih tubula NGAL i A1M, a radi usporedbe vrijednosti i korisnosti određivani su u serumu i uobičsjene tvari urea i kreatinin. U ovom su istraživanju prikazani rezultati prospektivne opažajne studije u koju je uključeno 158 ispitanika podvrgnutih planiranim srčanim operacijama uz uporabu izvantjelesnog krvotoka. Promatrao se uticaj hemodilucije u dvije skupine ispitanika. Skupina ispitanika s blagom hemodilucijom definirana je kao ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije veći od 60%, a skupina s umjerenom hemodilucijom je ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije manji od 60%. Iz rezultata ovog istraživanja može se zaključiti da umjerena hemodilucija tijekom srčanih operacijskih zahvata uz izvantjelesni krvotok koja nastaje razrjeđenjem krvi tzv. „priming“ otopinom izvantjelesnog krvotoka ima zaštitni učinak na funkciju proksimalnih bubrežnih tubula. Rani pokazatelji oštećenja proksimalnih bubrežnih tubula A1M i NGAL u urinu vrlo su korisni i osjetljivi za dokazivanje poremećaja u ranom poslijeoperacijskom vremenu nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. Navedeni pokazatelji imaju posebnu vrijednost u praćenju dinamike pri blažim subkliničkim oštećenjima proksimalnih bubrežnih tubula tijekom izvantjelesnog krvotoka. A1M je pokazao nešto veću osjetljivost i porast vrijednosti od NGAL. Tzv. „klasični“ pokazatelji bubrežnog oštećenja ureja i kreatinin u serumu nisu dovoljno osjetljivi za dokazivanje ranog i subkliničkog bubrežnog oštećenja nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. U studiji se na ispitanicima s prijeoperacijski normalom bubrežnom funkcijom nije pokazalo da transfuzijsko liječenje negativno utječe na funkciju proksimalnih bubrežnih tubula u prva 24 sata nakon srčanog operacijskog zahvata uz izvantjelesni krvotok. Rezultati istraživanja vidljivo pokazuju da duljina izvantjelesnog krvotoka značajno utječe na oštećenje bubrežne funkcije.Nowadays still a great number of heart surgeries is usually carried out with the use of the system of cardiopulmonary bypass. The system replaces the function of heart and lungs during the surgery which enables it. The technique of the system for cardiopulmonary bypass is nowdays very modern and to a great extent is adapted to physilogical functions of our organism. Despite that cardiopulmonary bypass has unwanted effects on some physiological functions of our organism. One of the negative physiological effects of cardiopulmonary bypass is a possible kidney damage. The frequency of kidney failure which happens after a surgery with the use of cardiopulmonary bypass is a possible kidney damage. The frequency of acute kidney failure which happens after heart surgeries with the use of cardiopulmonary bypass is about 1-5 %. The frequency of subclinical kidney damage is bigger and by routine traditional clinical tests it can hardly be proved in earlier stages. The traditional tests, the so called tests for diagnostic kidney damage, are serumal urea and the clearance of creatinine from urine and the analysis of the sediments of urine. Initial tubulo-interstitial changes are discovered with graet difficulty. However, they can be discovered in greater damages. Subclinical kidney damage, especially kidney tubules, can be proved in early indicators of kidney damage. The two mentioned indicators are highly specific early indicators of the damage of kidney tubules – the protein of law molecular mass alpha-1- microglobulin (A1M) and lipocalin associated with neutrophil gelatinase (NGAL) which are determined in urine. This paper primarily studied unwanted effects of cardiopulmonary bypass upon kidney damage, that is to say, the function of proximal tubules of kidneys and the influence and role of hemodilution on renal function caused by „priming“ solution. In order to define kidney damage, early indicators of damaged kidney proximal tubules NGAL and A1M were determined in urine and for the sake of comparison they were determined in serum as well as traditional tests of urea and creatinine. This research showed the results of a prospective study which included 158 subjects who were subjected to elective heart surgeries with the use of cardiopulmonary bypass. The influence of hemodilution was observed in two groups. The first group of subjects with mild hemodilution was defined as the one where the ratio of hematocrits after a surgery in comparison with hematocrits during the surgery was greater than 60%. The second group of subjects with moderate hemodilution was the group where the ratio of hematocrits after the surgery in comparison with hematocrits during the surgery was less than 60 %. This research shows that moderate hemodilution during heart surgeries accompanied by cardiopulmonary bypass which is caused by diluted blood, the so called „priming solution“ of cardiopulmonary bypass, has an important effect upon the function of proximal kidney tubules. Early indicators of the damage of proximal kidney tubules A1M and NGAL in urine are very helpful and sensitive in proving disorders in early postoperative period of time after heart surgeries accompanied by cardiopulmonary bypass. The mentioned indicators have special values in observing dynamics during milder subclinical damages of proximal kidney tubules during cardiopulmonary bypass. A1M showed slightly greater sensitivity and increase of value than NGAL. The so called „classical“ indicators of kidney damage urea and creatinine in serum are not enough sensitive to prove early and subclinical kidney damage after heart surgeries accompanied by cardiopulmonary bypass. The study did not show, that in subjects with preoperative normal kidney function, transfusion treatment has a negative effect on the function of proximal kidney tubules during 24 hours after a heart surgery accompanied by cardiopulmonary bypass. The results of the study show that the length of cardiopulmonary bypass singificantly infleunces the damage of kidney function

Effects of hemodilution on renal function after exposure of cardiopulmonary bypass

Danas se još uvijek velik broj rutinskih srčanih operacija uobičajeno izvodi uz uporabu sustava za izvantjelesni krvotok. Sustav zamjenjuje funkciju srca i pluća tijekom samog operacijskog zahvata što omogućava izvođenje operacijskog zahvata. Tehnika sustava za izvantjelesni krvotok danas je već jako napredna i u velikoj mjeri prilagođena fiziološkim funkcijama ljudskog tijela. Unatoč tome izvantjelesni krvotok ima i neželjene učinke na stanovite fiziološke funkcije organizma, a jedan od negativnih fizioloških učinaka izvantjelesnog krvotoka je moguće bubrežno oštećenje. Učestalost akutnog bubrežnog zatajenja koje se događa iza srčanih operacija uz uporabu izvantjelesnog krvotoka iznosi oko 1-5%. Učestalost subkliničkog bubrežnog oštećenja je veća, a primjenom uobičajenih kliničkih ispitivanja (ureja, kreatinin) teško se može dokazati u ranoj fazi liječenja. Tradicionalni su tzv. testovi za dijagnostiku oštećenja bubrega i to: serumska urea i kreatinin, klirens kreatinina iz urina te analiza sedimenta urina. Tim se i takvim laboratorijskim ispitivanjima teško otkrivaju početne tubulointersticijske promjene, a mogu se otkriti tek u poodmaklim jačim oštećenjima. Subkliničko bubrežno oštećenje, posebice bubrežnih tubula, može se dokazati ranim pokazateljima bubrežnog oštećenja. Dvoje od pokazatelja su visoko specifični rani pokazatelji oštećenja proksimalnih bubrežnih tubula. To su proteini niske molekulske mase alfa-1-mikroglobulin (A1M) i lipokalin udružen s neutrofilnom želatinazom (NGAL) koji se određuju u urinu i čija razina sadržaja ima značajnu dijagnostičku vrijednost. U ovome se znanstveno-istraživačkom radu prvenstveno promatrao neželjeni učinak izvantjelesnog krvotoka na oštećenje bubrega, tj. na funkciju proksimalnih tubula bubrega te utjecaj i uloga hemodilucije nastale „priming“ otopinom. Za definiranje bubrežnog oštećenja određivani su u urinu rani pokazatelji oštećenja bubrežnih tubula NGAL i A1M, a radi usporedbe vrijednosti i korisnosti određivani su u serumu i uobičsjene tvari urea i kreatinin. U ovom su istraživanju prikazani rezultati prospektivne opažajne studije u koju je uključeno 158 ispitanika podvrgnutih planiranim srčanim operacijama uz uporabu izvantjelesnog krvotoka. Promatrao se uticaj hemodilucije u dvije skupine ispitanika. Skupina ispitanika s blagom hemodilucijom definirana je kao ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije veći od 60%, a skupina s umjerenom hemodilucijom je ona u kojoj je omjer vrijednosti hematokrita nakon operacije s vrijednostima hematokrita tijekom operacije manji od 60%. Iz rezultata ovog istraživanja može se zaključiti da umjerena hemodilucija tijekom srčanih operacijskih zahvata uz izvantjelesni krvotok koja nastaje razrjeđenjem krvi tzv. „priming“ otopinom izvantjelesnog krvotoka ima zaštitni učinak na funkciju proksimalnih bubrežnih tubula. Rani pokazatelji oštećenja proksimalnih bubrežnih tubula A1M i NGAL u urinu vrlo su korisni i osjetljivi za dokazivanje poremećaja u ranom poslijeoperacijskom vremenu nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. Navedeni pokazatelji imaju posebnu vrijednost u praćenju dinamike pri blažim subkliničkim oštećenjima proksimalnih bubrežnih tubula tijekom izvantjelesnog krvotoka. A1M je pokazao nešto veću osjetljivost i porast vrijednosti od NGAL. Tzv. „klasični“ pokazatelji bubrežnog oštećenja ureja i kreatinin u serumu nisu dovoljno osjetljivi za dokazivanje ranog i subkliničkog bubrežnog oštećenja nakon srčanih operacijskih zahvata uz izvantjelesni krvotok. U studiji se na ispitanicima s prijeoperacijski normalom bubrežnom funkcijom nije pokazalo da transfuzijsko liječenje negativno utječe na funkciju proksimalnih bubrežnih tubula u prva 24 sata nakon srčanog operacijskog zahvata uz izvantjelesni krvotok. Rezultati istraživanja vidljivo pokazuju da duljina izvantjelesnog krvotoka značajno utječe na oštećenje bubrežne funkcije.Nowadays still a great number of heart surgeries is usually carried out with the use of the system of cardiopulmonary bypass. The system replaces the function of heart and lungs during the surgery which enables it. The technique of the system for cardiopulmonary bypass is nowdays very modern and to a great extent is adapted to physilogical functions of our organism. Despite that cardiopulmonary bypass has unwanted effects on some physiological functions of our organism. One of the negative physiological effects of cardiopulmonary bypass is a possible kidney damage. The frequency of kidney failure which happens after a surgery with the use of cardiopulmonary bypass is a possible kidney damage. The frequency of acute kidney failure which happens after heart surgeries with the use of cardiopulmonary bypass is about 1-5 %. The frequency of subclinical kidney damage is bigger and by routine traditional clinical tests it can hardly be proved in earlier stages. The traditional tests, the so called tests for diagnostic kidney damage, are serumal urea and the clearance of creatinine from urine and the analysis of the sediments of urine. Initial tubulo-interstitial changes are discovered with graet difficulty. However, they can be discovered in greater damages. Subclinical kidney damage, especially kidney tubules, can be proved in early indicators of kidney damage. The two mentioned indicators are highly specific early indicators of the damage of kidney tubules – the protein of law molecular mass alpha-1- microglobulin (A1M) and lipocalin associated with neutrophil gelatinase (NGAL) which are determined in urine. This paper primarily studied unwanted effects of cardiopulmonary bypass upon kidney damage, that is to say, the function of proximal tubules of kidneys and the influence and role of hemodilution on renal function caused by „priming“ solution. In order to define kidney damage, early indicators of damaged kidney proximal tubules NGAL and A1M were determined in urine and for the sake of comparison they were determined in serum as well as traditional tests of urea and creatinine. This research showed the results of a prospective study which included 158 subjects who were subjected to elective heart surgeries with the use of cardiopulmonary bypass. The influence of hemodilution was observed in two groups. The first group of subjects with mild hemodilution was defined as the one where the ratio of hematocrits after a surgery in comparison with hematocrits during the surgery was greater than 60%. The second group of subjects with moderate hemodilution was the group where the ratio of hematocrits after the surgery in comparison with hematocrits during the surgery was less than 60 %. This research shows that moderate hemodilution during heart surgeries accompanied by cardiopulmonary bypass which is caused by diluted blood, the so called „priming solution“ of cardiopulmonary bypass, has an important effect upon the function of proximal kidney tubules. Early indicators of the damage of proximal kidney tubules A1M and NGAL in urine are very helpful and sensitive in proving disorders in early postoperative period of time after heart surgeries accompanied by cardiopulmonary bypass. The mentioned indicators have special values in observing dynamics during milder subclinical damages of proximal kidney tubules during cardiopulmonary bypass. A1M showed slightly greater sensitivity and increase of value than NGAL. The so called „classical“ indicators of kidney damage urea and creatinine in serum are not enough sensitive to prove early and subclinical kidney damage after heart surgeries accompanied by cardiopulmonary bypass. The study did not show, that in subjects with preoperative normal kidney function, transfusion treatment has a negative effect on the function of proximal kidney tubules during 24 hours after a heart surgery accompanied by cardiopulmonary bypass. The results of the study show that the length of cardiopulmonary bypass singificantly infleunces the damage of kidney function

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

Ceftazidime/ Avibactam for Treatment of Intrahospital Ventilator-Associated Pneumonia in COVID-19 Patients

U razdoblju pandemije koronavirusne bolesti 2019. (COVID-19) mnogi bolesnici kojima je bila potrebna invazivna mehanička ventilacija, primljeni su u jedinice intenzivnog liječenja (JIL) zbog teškog respiratornog zatajenja povezanog s bolešću COVID-19. Prijam u JIL i invazivna mehanička ventilacija neovisni su rizici za pneumoniju povezanu s ventilatorom (engl. ventilator associated pneumonia; VAP), kod koje je zabilježena visoka stopa smrtnosti i dulji boravak u JIL-u te je produljeno bolničko liječenje. Ako govorimo o uzročnicima VAP-a, Pseudomonas aeruginosa bio je jedan od glavnih gram-negativnih nefermentirajućih uzročnika ove patologije, zajedno s Burkholderia cepacia i Stenotrophomonas maltophilia u manjoj mjeri. Protiv gram-negativnih mikroorganizama otpornih na karbapeneme, ceftazidim/avibaktam (CZA) jedan je od najčešće korištenih antimikrobnih lijekova. Cilj ovog preglednog članka bio je opisati korištenje CZA u liječenju bolesnika s infekcijom COVID-19 koji su razvili VAP uzrokovan P. aeruginosa, B. cepacia i S. maltophilia, usporediti to s podatcima objavljenim u literaturi te skrenuti pozornost na kontinuiranu primjenu lijeka kao drugačijeg modaliteta u odnosu na standardni način primjene u bolusu. Unatoč visokoj smrtnosti kritično oboljelih bolesnika s COVID-om, CZA predstavlja valjanu opciju liječenja VAP-a uzrokovanog nefermentirajućim gram-negativnim mikroorganizmima.In the period of the coronavirus diseFase 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to the intensive care unit (ICU) due to severe respiratory failure associated with COVID-19 infection. In fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with a high mortality rate and longer ICU and hospital stays. Pseudomonas aeruginosa was the first causative agent of this pathology (VAP), but rare non-fermenting Gram-negative microorganisms such as Burkholderia cepacea and Stenotrophomonas maltophilia have also emerged as potential etiological agents. One of the most frequently used antibiotics against carbapenem- resistant Gram-negative microorganisms is ceftazidime/avibactam (CZA). The aim of this review article was to describe the use of CZA in a series of cases of patients with COVID-19 infection who developed difficult-to-treat VAP due to P. aeruginosa, B. cepacea and S. maltophilia and to compare it with data published in the literature, as well as to draw attention to the continuous administration of the drug as a different modality compared to the standard method of bolus administration. Despite the high mortality of critically ill patients with COVID-19, CZA, especially in combination therapy, could represent a valid treatment option for VAP caused by non-fermenting Gram-negative microorganisms