Upala pluća uzrokovana ventilatorom: usporedba bolesnika s kadaveričnim presatkom jetre i kirurških bolesnika bez presatka

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes.Upala pluća uzrokovana ventilatorom česta je komplikacija u jedinicama intenzivnog liječenja kirurških bolesnika, naročito onih s visokim stupnjem disfunkcije organa kod prijma. Ispitivala se učestalost i klinički ishod upale pluća uzrokovane ventilatorom kod bolesnika podvrgnutih velikim abdominalnim operativnim zahvatima te kod bolesnika nakon kadaverične transplantacije jetre. U studiju su bili uključeni bolesnici koji su u Jedinici intenzivnog liječenja boravili duže od četiri dana, koji su prošli operaciju ili transplantaciju te koji su bili mehanički ventilirani duže od 48 sati. Dijagnoza se temeljila na kombinaciji radioloških znakova (progresija infiltrata na snimkama prsišta), kliničkih znakova (vrućica >38,3 °C, leukociti >12×109/mL) te mikrobioloških podataka (pozitivna kultura aspirata traheje >105 i/ili bronhoalveolarnog lavata >104 kolonije/mL). Pregledani su medicinski zapisi 1037 bolesnika od kojih je njih 157 bilo mehanički ventilirano duže od 48 sati: 62 transplantiranih i 95 netransplantiranih. Samo 39 (24,84%) bolesnika zadovoljilo je kriterije. Nije nađena razlika u spolu, dobi, trajanju mehaničke ventilacije, duljini boravka ili ishodu između ispitivanih skupina. Međutim, glavnu razliku činio je bodovni sustav disfunkcije organa kod prijma (Simplifi ed Acute Physiology Score II), koji je bio veći kod netransplantiranih bolesnika (42±16 prema 31±9; p=0,03). Multirezistentne gram-negativne bakterije bile su vodeći uzročnik (82,03%). U jedinicama intenzivnog liječenja kirurških bolesnika transplantacija jetre sama po sebi ne povećava rizik za nastanak upale pluća uzrokovane ventilatorom kao ni lošiji ishod tih bolesnika

Treatment of haemorrhagic shock: a case report

Te aim of this case report is to demonstrate that during extensive and long-lasting mutilating operations it is necessary to use an aggressive volume replacing approach to maintain adequate tissue oxygenation. A satisfactory level of tissue oxygenation is necessary to uphold the function and structure of cells, tissue and organs. Monitoring the haemodynamic function during the operation is an important task for the anaesthesiologist. We present a case of a 58-year-old woman with widespread malignant disease, who underwent surgical treatment in our hospital. Te operation was mutilating and longlasting. During the perioperative period the patient received a large volume of fuids and blood products due to extensive intraoperative blood loss. High doses of vasoactive drugs were also introduced to achieve haemodynamic stability. Due to adequate and aggressive volume replacement, haemodynamic stability was eventually achieved and the outcome was benefcial for our patient

Viscoelastic hemostatic tests during liver transplantation – have we changed blood transfusion therapy?

Uvod: Transplantacija ili presađivanje jetre jest priznata metoda liječenja kojom se terminalno bolesna jetra zamjenjuje sa zdravom jetrom darivatelja. Standardni laboratorijski testovi (protrombinsko vrijeme, aktivirano parcijalno tromboplastinsko vrijeme, fibrinogen, antitrombin), premda koreliraju s težinom jetrene bolesti, pokazali su inferiornost u odnosu na viskolelastične testove (trombelastogram – TEG i rotacijska trombelastometrija – ROTEM) u procjeni funkcije koagulacijskog sustava u terminalnoj fazi jetrene bolesti. Cilj ovog istraživanja bio je utvrditi na koji je način intraoperacijska upotreba viskolestičnih testova u procjeni hemostaze tijekom transplantacije jetre utjecala na transfuzijsko liječenje u Kliničkoj bolnici Merkur. Metode: Ovom retrospektivnom, opservacijskom studijom analizirane su slijedeće varijable za 76 pacijenta iz 2010. (bez ROTEM-a) te 82 pacijenta iz 2021. (s ROTEM-om) kojima je u KB Merkuru transplantirana jetra : intraoperacijska nadoknada tekućinama (kristaloidne, koloidne otopine); transfuzijsko liječenje krvnim derivatima (deplazmatizirani koncentrati eritrocita, svježe smrznuta plazma, trombociti, krioprecipitat); ukupni intraoperacijski gubitci (krv, diureza, međustanični prostor); ukupna nadoknada tekućinama i krvnim derivatima. Rezultati: Tijekom 2010. prosječna ukupna nadoknada tekućinama i krvnim derivatima bila je 18 433 ml dok je za 2021. bila 9838 ml (p<0,0001). Prosječni volumen kristaloidnih otopina ordiniranih 2010. tijekom transplantacije jetre bio je 5674 ml dok je 2021. bio 4734 ml (p=0,0015); koloidnih 2010. godine 2244 ml, a koloidnih 2021. godine 1949 ml (p=0,07). Prosječna količina deplazmatiziranih eritrocita ordinirana 2010. bila je 2927 ml dok je 2021. bila 1266 ml (p<0,0001). Prosječna količina svježe smrznute plazme, trombocita i krioprecipitata ordiniranih 2010. bila je 5428, 426, 266 ml dok je 2021. bila 823 (p<0,0001), 137 (p<0,0001), 366 ml (p<0,03). Zaključak: Uporabom viskoelastičnih testova za praćenje hemostaze tijekom transplantacije jetre značajno je smanjeno davanje svih krvnih derivata, osim krioprecipitata čija potrošnja je povećana, a nije utjecala na količinu ordiniranih koloidnih otopina. Smanjenje količine krvnih derivata je od iznimnog značaja s obzirom na rizike koje nosi transfuzijsko liječenje.Introduction: Liver transplantation is a viable treatment for end stage liver desease in which a terminally ill liver is replaced with a healthy donor liver. Standard laboratory tests (prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin), although correlates with the severity of liver disease, showed inferiority to viscolelastic tests (thrombelastogram – TEG, rotational thrombelastometry – ROTEM) in the assessment of coagulation in the end stage liver desease. The aim of this study was to determine if the intraoperative use of viscolastical tests during liver transplantation have influenced amount of administered blood products. Methods: This retrospective, observational study analyzed the following variables for 76 patients in 2010. (without ROTEM) and 82 patients in 2021. (with ROTEM) who underwent liver transplantation at University Hospital Merkur: intraoperative fluid replacement (crystalloid, colloid); blood products (deplasmatized erythrocytes, fresh frozen plasma, platelets, cryoprecipitate); total intraoperative fluide losses (blood, diuresis, intercellular space); total compensation of fluids and blood products. Results: In 2010. the average total compensation of fluids and blood products was 18,433 ml, while in 2021. it was 9,838 ml (p <0.0001). Volume of crystalloids administered in 2010. was 5674 ml, in 2021. 4734 ml (p = 0.0015); colloids in 2010. 2244 ml, in 2021. 1949 ml (p = 0.07). Deplasmated erythrocytes administered in 2010. were 2927 ml while in 2021. 1266 ml (p <0.0001). Fresh frozen plasma, platelets and cryoprecipitates administered in 2010. were 5428, 426, 266 ml, in 2021. it was 823 (p <0.0001), 137 (p <0.0001), 366 ml (p <0, 03). Conclusion: The use of viscoelastic tests to monitor hemostasis during liver transplantation significantly reduced the administration of all blood products, except cryoprecipitates whose consumption was increased and did not affect the amount of administered colloids. Reducing the amount of blood products is important given the risks related to transfusion of blood products

Ventilator-associated pneumonia: comparing cadaveric liver transplant and non-transplant surgical patients

Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infiltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×109/mL) and microbiological data (positive culture from tracheal aspiration >105 or bronchoalveolar lavage >104 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. There were no differences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main difference was the mean severity score on admission (Simplified Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes