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

The position of women managers

Položaj žena u poslovnom svijetu nije se puno istraživao. Nedostatak literature najbolje govori kako je problem položaja žena u poslovnom svijetu slabo istraženo područje na ovom području Europe. Dosadašnja istraživanja pokazuju kako društvo u kojem živimo najviše utječe na položaj žena u poslovnom svijetu. Na ovom našem području društvo je još uvijek patrijarhalno te je uvriježeno mišljenje da žena nije sposobna za najviša mjesta te da je menadžerski posao još uvijek zauzet samo za muškarce. Samostalno provedeni intervju na uzorku od desetak osoba, donio je slične rezultate kao i dosadašnja istraživanja. Nova istraživanja govore kako bi menadžeri trebali biti psiholozi, sociolozi i etičari, to jest posjedovati vještine koje se pripisuju muškarcima. Postavlja se pitanje da li je menadžer 21. stoljeća- žena?The position of women in the business world is not much explored . The lack of literature is best explained as a problem of women in the business world poorly explored area in this region of Europe . Previous studies show that the society we live in the greatest impact on the status of women in the business world . In this area of our society is still patriarchal and the view that a woman is not capable of the highest places , and that the managerial job is still busy just for men . Independently conducted interviews with a sample of ten people , has brought similar results to previous studies . New studies suggest that the managers should be psychologists , sociologists and ethicists , that is equipped with the skills attributed to men . The question is the question is whether the manager of the 21st century- woman

Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

Intra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients was analysed. Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk factors for IAH. Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley catheter placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05 was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg. Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus 1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients). Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group. Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with consequent multi-organ failure, and for timely application of efficacious therapeutic procedures

Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

Intra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients was analysed. Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk factors for IAH. Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley catheter placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05 was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg. Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus 1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients). Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group. Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with consequent multi-organ failure, and for timely application of efficacious therapeutic procedures

Extravascular lung water index as an indicator of lung injury in septic patients

Introduction. Transpulmonary thermodilution using PiCCO (Pulse-induced Contour Cardiac Output) is a standard minimally invasive method used for haemodynamic monitoring. Objectives. The goal of this paper is to examine the correlation and dynamics of the ExtraVascular Lung Water Index (EVLWI) as an indicator of acute lung injury in septic patients who underwent major abdominal surgery. Two groups of patients were selected: the ones with ALI (Acute Lung Injury): ALI patient group, and the ones without ALI: non-ALI patient group. A correlation between EVLWI and other haemodynamic and respiratory data in both groups were analyzed. Materials and methods. The study included 48 patients. Throughout the seven-day period EVLWI, GEDVI (Global End-Diastolic Volume Index), ITBVI (IntraThoracic Blood Volume Index), CI (Cardiac Index), SVRI (Systemic Vascular Resistance Index) were measured in both groups using PiCCO monitoring over 8-hour intervals as well as heart rate, mean arterial pressure, serum albumin concentration, PaCO2 (arterial partial pressure of carbon dioxide), PaO2 (arterial partial pressure of oxygen), PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio, lung compliance, lung resistance and ScvO2 (central venous oxygen saturation). All patients were analgosedated, intubated, mechanically ventilated, in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and Sequential Organ Failure Assessment (SOFA) scores calculated. Ventilator settings and dosage of vasoactive drugs were kept constant during the study. Results. EVLWI was significantly higher in ALI patients group compared to non-ALI patients group. In patients with ALI group 11/22 patients died (50%), in the non-ALI patients group 6/26 patients died (23%). EVLWI was significantly higher in patients that died compared to ones who survived. Conclusion. EVLWI is a good indicator of early acute lung injury in surgical patients with sepsis

Multiple Structural Failures of Aortic Homografts Leading to Emergency Surgery

Aortic homografts are composed of aortic roots and variable lengths of the arch and ascending aorta, harvested from donor hearts. They are primarily used in extensive aortic root endocarditis due to its resistance to reinfection. They are, however, prone to structural failure. Redo aortic root surgery is challenging, especially in the setting of aneurysms or pseudoaneurysms (PSAN) lying immediately posterior to the sternum or adhering to it. We present a 43-year-old female with two aortic homograft pseudoaneurysms following her fourth aortic valve and ascending aortic procedure. The first PSAN was described as immediately cranial to proximal homograft anastomosis, measuring 21x8 millimeters. It harbored potential for intraoperative rupture because of its proximity to the posterior sternal table. The second one was 36x20 millimeters, adjacent to the distal homograft anastomosis. The surgical plan entailed institution of peripheral hypothermic cardiopulmonary bypass due to an almost inevitable risk of bleeding from the retrosternal pseudoaneurysm. While the actual sternotomy was uneventful, the PSAN ruptured after sternal retraction. The ensuing massive bleeding was expected and was success- fully managed during hypothermic circulatory arrest. The patient had an unremarkable postoperative course and was discharged home

Liver injury after the intravenous amiodarone administration in patient with impaired heart function

While many adverse effects have been associated with long-term oral amiodarone therapy, acute hepatotoxicity from intravenous administration of amiodarone is a rare side effect. This case report focuses on a 78-year-old critically ill female, who underwent several urgent surgical procedures and had elevated liver aminotransferases concentrations after the intravenous administration of amiodarone for the treatment of atrial fibrillation. Also, the patient developed heart failure with reduced left ventricular systolic function. Immediately after the discontinuation of amiodarone therapy, liver aminotransferases levels began to decline. Our case suggests that regular monitoring of hepatic function is required in patients receiving intravenous amiodarone, especially in the setting of impaired heart function and possible liver hypoperfusion

Inhalation plus intravenous colistin versus intravenous colistin alone for treatment of ventilator associated pneumonia

In the setting of intensive care units the incidences of multi-drug resistant gram-negative (MDR-GN) pathogens causing ventilator associated pneumonia (VAP) has increased, leading clinicians to use colistin. Our aim was to assess outcomes associated with the use of inhalation and intravenous colisitn versus only intravenous colistin in patients with MDR-GN VAP. A retrospective, single centre study at University Hospital Centre, Zagreb. Patients were divided in two groups, according to their administration of antibiotics – inhalation and intravenous (INH+IV) administration for 8 patients or intravenous only (IV) administration for 23 patients. The results showed that demographic and clinical characteristics and the gram negative pathogens isolated were similar between the two groups, except for K. pneumoniae, which was higher in the IV group. No statistically significant difference between the two groups were observed regarding intensive care unit mortality (P=0.951), sepsis (P=0.474), acute respiratory distress syndrome (P=0.548), length of ICU stay (P=0.686) and length of mechanical ventilation (P=0.858). A statistically significant difference was found regarding the eradication of pathogens in respiratory cultures (P= 0.018). The addition of inhalation to intravenous colistin in MDR-GN VAP improves microbiologic outcome, but does not improve ICU mortality in these patients. Larger prospective trials are warranted to confirm the benefit of adjunctive inhalation colistin as a MDR-GN VAP therapy in the critically ill

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

STROKE VOLUME AND PULSE PRESSURE VARIATION ARE GOOD PREDICTORS OF FLUID RESPONSIVENESS IN SEPSIS PATIENTS

Tehnologijom LiDCOPlusTM ispitali smo vrijednost varijacije udarnog volumena (SVV - Stroke Volume Variation) i tlaka pulsa (PPV - Pulse Pressure Variation) u predviđanju odgovora na liječenje nadoknadom volumena u bolesnika sa sepsom nakon velikih abdominalnih kirurških zahvata. Ukupno je bilo 46 bolesnika (22 muškaraca u dobi od 46±6 godina, APACHE II zbroj 26±5; 24 žene u dobi od 41±6 godina, APACHE II zbroj 24±4). Sepsa je definirana prema međunarodnim kriterijima. Pozitivan odgovor na bolus 500 mL 6 % hidroksietil škroba smatrao se porast indeksa udarnog volumena (SVI - Stroke Volume Index) ≥15 %. Rezultati su uspoređeni Studentovim t-testom, korelacija Pearsonovim koeficijentom. Pozitivni odgovor primijećen je u 26 (57,4 %) bolesnika. Početne vrijednosti SVV korelirale su sa početnim vrijednostima PPV (r=0,92, P<0,001). SVV i PPV su bili značajno viši kod bolesnika s pozitivnim odgovorom. SVV: 14,4 ±3,3 vs. 7,1 ±3,1; P <0,001. PPV: 15,2±4,1 vs. 7,4±4,5; P<0,001. Nije bilo razlike između AUROC (Area Under Receiver Operating Characteristic) krivulja za SVV (0,96; 95 % confidence interval 0,859-0,996) i PPV (1,000; 95 % confidence interval 0,923-1,000). Optimalna vrijednost diskriminacijskog praga bila je 10 % za SVV (osjetljivost 96,15 %, specifičnost 100 %) i 12 % za PPV (osjetljivost 100 % i specifičnost 100 %). Rezultati upućuju da su SVV i PPV dobri pokazatelji hemodinamskog odgovora na nadoknadu tekućine u sepsi.Stroke volume variation (SVV) and pulse pressure variation (PPV) are dynamic preload indicators. Specific interactions of the cardiovascular system and lungs under mechanical ventilation cause cyclic variations of SVV and PPV. Real time measurement of SVV and PPV by arterial pulse contour analysis is useful to predict volume responsiveness in septic patients. Results of a prospective, 2-year observational study conducted at Department of Anesthesiology, Resuscitation and Intensive Care, Zagreb University Hospital Center, are presented. Volume responders and non-responders were defined. Correlation between SVV, PPV, stroke volume index (SVI) and other hemodynamic data in septic patients was analyzed. The study was conducted from September 2009 to December 2011. Sepsis group included 46 patients (22 male, age 46±6, APACHE II score 26±5, and 24 female, age 41±6, APACHE II score 24±4) undergoing major abdominal surgery with clinically and laboratory confirmed sepsis, defined according to the international criteria. Exclusion criteria: patients with LVEF <45%, atrial fibrillation, aortic insufficiency, pulmonary edema, children, pregnant women, patients on lithium therapy, and patients who did not sign informed consent. Septic patients were divided into volume responders (VR) and volume non-responders (VNR). Responders were defined as patients with an increase in SVI of ≥15% after fluid loading. SVV, PPV and SVI were assessed by arterial pulse contour analysis using the LiDCOTM plus system continuously for 8 hours. Simultaneously, cardiac index (CI), mean arterial pressure (MAP), heart rate (HR), oxygen delivery (DO2), oxygen consumption (VO2) and central venous oxygen saturation (ScvO2) were assessed. Hemodynamic data were recorded before and after fluid administration of 500 mL of 6% hydroxyethyl starch over 30 min. All patients were sedated with midazolam (0.05-0.15 mg/kg/h). Analgesia was maintained with sufentanil (0.2-0.6 μg/kg). All patients were intubated and mechanically ventilated (IPPV; FiO2 0.4; TV 7 mL/kg; PEEP 5 cm H2O) in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and SOFA scores calculated. Ventilator settings and dosage of vasoactive drugs were all kept constant during the study. Data were compared using Student’s t-test. Correlation was estimated using Pearson’s coefficient. The level of statistical significance was set at P<0.05. Positive response to fluid loading was present in 26 (57.4%) patients. Baseline SVV correlated with baseline PPV (r=0.92, P<0.001). SVV and PPV were significantly higher in responders than in nonresponders. SVV: 14.4±3.3 vs. 7.1±3.1; P<0.001. PPV: 15.2±4.1 vs. 7.4±4.5; P<0.001. Other hemodynamic parameters measured were statistically different between the two groups. Only DO2 values showed no statistical significance between the responders and non-responders. There was no difference between the area under receiver operating characteristic curves of SVV (0.96; 95% confidence interval 0.859-0.996) and PPV (1.000; 95% confidence interval 0.93-1.000). Optimal threshold value for discrimination between VR and VNR was 10% for SVV (sensitivity 96.15%, specificity 100%) and 12% for PPV (sensitivity 100%, specificity 100%). In conclusion, SVV and PPV measured by LiDCOTM plus system are reliable predictors of fluid responsiveness in mechanically ventilated septic patients in sinus cardiac rhythm