Stalni nadzor srčanog izbačaja metodama Picco i Lidco prema Pak-u u septičnih bolesnika: kalibrirati ili ne ?

The accuracy of cardiac output measurement by two most widely used methods of less invasive hemodynamic monitoring and by the standard technique of thermodilution with pulmonary catheter was assessed. The measurements were carried out in septic surgical patients immediately after and between system calibrations. Study results showed satisfactory compatibility of measurements performed by the two methods and by pulmonary catheter in both phases, thus system calibration being recommendable in hemodynamically unstable septic patients.U ovom radu uspoređivala se točnost mjerenja srčanog izbačaja pomoću dviju najčešće upotrebljavanih metoda manje invazivnog hemodinamskog nadzora i standardnom tehnikom termodilucije plućnim kateterom. Mjerenje je provedeno kod septičnih kirurških bolesnika u razdoblju neposredno nakon i između kalibracija sustava. Rezultati su pokazali zadovoljavajuću podudarnost mjerenja u obje faze primjenom obiju metoda i pomoću plućnog katetera, pa se kalibriranje sustava preporuča u hemodinamski nestabilnih septičnih bolesnika

Early complications of percutaneous tracheostomy using the Griggs method

This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods

Early complications of percutaneous tracheostomy using the Griggs method

This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods

Smjernice Hrvatskog društva za hematologiju i transfuzijsku medicinu u dijagnostičko-terapijskom postupku za trombocitopeniju izazvanu heparinom (HIT) [Croatian Society for Haematology and Transfusion Medicine Guidelines on the diagnosis and management of heparin induced thrombocytopenia (HIT)]

Heparin induced thrombocytopenia (HIT) is a serious complication of heparin administration. In the last decade, this clinical syndrome has come into the focus of interest, primarily because of the severe thromboembolic complications that may lead to lethal outcome. In addition, great improvements have been made in the treatment with direct thrombin inhibitors and in laboratory diagnosis of HIT. As guidelines for diagnostic and management of HIT upgrade the quality of patient treatment, activities for their development have been launched in the Republic of Croatia. Based on British Committee for Standards in Haematology (BCSH) recommendations on diagnostic and treatment of HIT from 2006, activities for the introduction of new assays for anti-heparin antibodies were launched in 2008 and 2009, including algorithm of laboratory testing for HIT, sheet for clinical assessment of HIT (4T score), and education oftransfusiologists and clinicians. Upon evaluation of the results collected during one-year period, the Croatian Society of Haematology and Transfusion Medicine nominated a task force for the development of guidelines for HIT in January 2010. Following wide-ranging discussion, the guidelines were adopted in May 2011

Razine humanog topljivog TREM-1 u plućima i serumu bolesnika s bakterijskom upalom pluća povezanom s uređajem za umjetno disanje

Human soluble triggering receptor expressed on myeloid cells (sTREM -1) is a glycoprotein of the immunoglobulin superfamily. In normal lung tissue, sTREM -1 is selectively expressed in lung alveolar macrophages specialized for pathogen clearance and is up-regulated in the presence of bacteria and fungi. The aim of this study was to assess sTREM -1 levels in serum and lungs of patients with ventilator associated pneumonia (VAP) and to evaluate its potential diagnostic role. The study cohort included 31 patients meeting the criteria for VAP, including clinical, microbiological, radiological and laboratory findings in patients on mechanical ventilation for more than 48 hours and with Clinical Pulmonary Infection Score (CPIS) >6. Serum and lung levels of sTREM -1 were obtained and tested for differences. The samples were analyzed using ELI SA technique and the values were expressed in pg/mL. The samples for lung sTREM -1 were obtained from direct bronchial lavage fluid and serum samples from peripheral blood. Differences were tested by Mann Whitney U test with p<0.05 considered significant. In patients with bacterial VAP, a statistically significant difference was found between serum and lung sTREM -1 levels (p<0.05), with very high levels of sTREM -1 recorded in lung samples (mean value 1565 pg/mL). There was no statistically significant difference in pulmonary sTREM -1 level between the polymicrobial and monomicrobial VAP groups. In conclusion, sTREM -1 is present in a high concentration in the lungs of patients with bacterial VAP. sTREM -1 levels can help in making the diagnosis of bacterial pneumonia as a standalone marker.Humani topljivi okidački receptor izražen na mijeloidnim stanicama (sTREM -1) je glikoprotein iz superporodice imunoglobulina. U normalnom plućnom tkivu sTREM -1 je selektivno izražen na makrofazima plućnih alveola, koji su specijalizirani za uklanjanje patogena, te podliježe regulaciji naviše u prisutnosti bakterija i gljiva. Cilj ove studije bio je procijeniti razine sTREM -1 u serumu i plućima bolesnika s upalom pluća povezanom s uređajem za umjetno disanje (VAP), kao i njegovu moguću dijagnostičku vrijednost. Ispitivanje je obuhvatilo 31 bolesnika koji su zadovoljavali kriterije za VAP, uključujući kliničke, mikrobiološke, radiološke i laboratorijske nalaze bolesnika priključenih na mehaničku ventilaciju kroz više od 48 sati i sa zbirom CPIS (Clinical Pulmonary Infection Score) većim od 6. Izmjerene su serumske i plućne razine sTREM -1 i izračunate razlike među njima. Uzorci su analizirani pomoću tehnike ELI SA, a vrijednosti su izražene u pg/mL. Uzorci za procjenu sTREM -1 u plućima dobiveni su direktnom bronhijalnom lavažom, a uzorci seruma iz periferne krvi. Razlike su testirane Mann Whitneyevim U testom uz razinu značajnosti P<0,05. Kod bolesnika s bakterijskom VAP utvrđena je statistički značajna razlika između serumske i plućne razine sTREM -1 (P<0,05), uz vrlo visoke razine sTREM -1 zabilježene u plućnim uzorcima (srednja vrijednost 1565 pg/mL). Nije bilo statistički značajne razlike u plućnoj razini sTREM -1 između skupina s polimikrobnom i monomikrobnom VAP. U zaključku, sTREM -1 je prisutan u visokoj koncentraciji u plućima bolesnika s bakterijskom VAP, pa bi stoga razine sTREM -1 mogle biti korisne u postavljanju dijagnoze bakterijske upale pluća kao jedan jedinstveni biljeg

Razine humanog topljivog TREM-1 u plućima i serumu bolesnika s bakterijskom upalom pluća povezanom s uređajem za umjetno disanje

Human soluble triggering receptor expressed on myeloid cells (sTREM -1) is a glycoprotein of the immunoglobulin superfamily. In normal lung tissue, sTREM -1 is selectively expressed in lung alveolar macrophages specialized for pathogen clearance and is up-regulated in the presence of bacteria and fungi. The aim of this study was to assess sTREM -1 levels in serum and lungs of patients with ventilator associated pneumonia (VAP) and to evaluate its potential diagnostic role. The study cohort included 31 patients meeting the criteria for VAP, including clinical, microbiological, radiological and laboratory findings in patients on mechanical ventilation for more than 48 hours and with Clinical Pulmonary Infection Score (CPIS) >6. Serum and lung levels of sTREM -1 were obtained and tested for differences. The samples were analyzed using ELI SA technique and the values were expressed in pg/mL. The samples for lung sTREM -1 were obtained from direct bronchial lavage fluid and serum samples from peripheral blood. Differences were tested by Mann Whitney U test with p<0.05 considered significant. In patients with bacterial VAP, a statistically significant difference was found between serum and lung sTREM -1 levels (p<0.05), with very high levels of sTREM -1 recorded in lung samples (mean value 1565 pg/mL). There was no statistically significant difference in pulmonary sTREM -1 level between the polymicrobial and monomicrobial VAP groups. In conclusion, sTREM -1 is present in a high concentration in the lungs of patients with bacterial VAP. sTREM -1 levels can help in making the diagnosis of bacterial pneumonia as a standalone marker.Humani topljivi okidački receptor izražen na mijeloidnim stanicama (sTREM -1) je glikoprotein iz superporodice imunoglobulina. U normalnom plućnom tkivu sTREM -1 je selektivno izražen na makrofazima plućnih alveola, koji su specijalizirani za uklanjanje patogena, te podliježe regulaciji naviše u prisutnosti bakterija i gljiva. Cilj ove studije bio je procijeniti razine sTREM -1 u serumu i plućima bolesnika s upalom pluća povezanom s uređajem za umjetno disanje (VAP), kao i njegovu moguću dijagnostičku vrijednost. Ispitivanje je obuhvatilo 31 bolesnika koji su zadovoljavali kriterije za VAP, uključujući kliničke, mikrobiološke, radiološke i laboratorijske nalaze bolesnika priključenih na mehaničku ventilaciju kroz više od 48 sati i sa zbirom CPIS (Clinical Pulmonary Infection Score) većim od 6. Izmjerene su serumske i plućne razine sTREM -1 i izračunate razlike među njima. Uzorci su analizirani pomoću tehnike ELI SA, a vrijednosti su izražene u pg/mL. Uzorci za procjenu sTREM -1 u plućima dobiveni su direktnom bronhijalnom lavažom, a uzorci seruma iz periferne krvi. Razlike su testirane Mann Whitneyevim U testom uz razinu značajnosti P<0,05. Kod bolesnika s bakterijskom VAP utvrđena je statistički značajna razlika između serumske i plućne razine sTREM -1 (P<0,05), uz vrlo visoke razine sTREM -1 zabilježene u plućnim uzorcima (srednja vrijednost 1565 pg/mL). Nije bilo statistički značajne razlike u plućnoj razini sTREM -1 između skupina s polimikrobnom i monomikrobnom VAP. U zaključku, sTREM -1 je prisutan u visokoj koncentraciji u plućima bolesnika s bakterijskom VAP, pa bi stoga razine sTREM -1 mogle biti korisne u postavljanju dijagnoze bakterijske upale pluća kao jedan jedinstveni biljeg

Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation

Maternal brain death during pregnancy remains an exceedingly complex situation that requires not only a well-considered medical management plan, but also careful decision-making in a legally and ethically delicate situation. Management of brain dead pregnant patients needs to adhere to special strategies that support the mother in a way that she can deliver a viable and healthy child. Brain death in pregnant women is very rare, with only a few published cases. We present a case of a pregnant woman with previously diagnosed multiple brain cavernomas that led to intracranial hemorrhage and brain stem death during the 21st week of pregnancy. The condition that can be proven unequivocally, using tests that do not endanger viability of the fetus, is brain stem death, diagnosed through absence of cranial reflexes. The patient was successfully treated until delivery of a healthy female child at 29 weeks of gestation. The patient received continuous hormone substitution therapy, fetal monitoring and extrinsic regulation of maternal homeostasis over 64 days. After delivery, the final diagnosis of brain death was established through multi-slice computerized tomography pan-angiography. This challenging case discusses ethical and medical circumstances arising from a diagnosis of maternal brain death, while showing that prolongation of somatic life support in a multidisciplinary setting can result in a successful pregnancy outcome

Comparison of ultrasonographic measurement of optic nerve sheath diameter (ONSD) versus direct measurement of intracranial pressure (ICP) in traumatic brain injury patients

Aim. To compare ultrasonographic measurement of optic nerve sheath diameter (ONSD) with direct measurement of intracranial pressure (ICP) and evaluate the correlation between them in traumatic brain injury patients. Patients and methods. Twenty traumatic brain injury patients were enrolled in the study. Patients had a median Glasgow Coma Scale (GCS) score of 5. All patients underwent noninvasive measurement of ICP by ultrasonographic measurement of ONSD and invasive ICP measurement using an intraventricular catheter. We used MedCalc to analyze data. Results. We compared the ONSD measurement in patients with ICP less than 20 cm H2O with patients with ICP greater than 20 cm H2O. The mean ONSD for 8 patients with ICP > 20 cmH2O was 7.6 +/- 0.8 mm, and for 18 patients with ICP 20 cm H2O was 6.1, with sensitivity of 100 % and specificity of 83 %. (the area under the curve was 0.98, 95 % CI = 0.825-0.990). In this study, the usually used cutoff of ONSD > 5 mm gives a sensitivity of 100 %, but a specificity of only 22 %. Conclusion. Ultrasonographic measurement of ONSD correlates with direct measurement of ICP. This method has potential as a screening test for elevated ICP in traumatic brain injury

Croatian Society for Haematology and Transfusion Medicine Guidelines on the Diagnosis and Management of Heparin Induced Thrombocytopenia (HIT)

Trombocitopenija izazvana heparinom (HIT) teška je nuspojava heparinske terapije. U posljednjih desetak godina ovaj kliničkopatološki sindrom u središtu je interesa primarno zbog teških tromboembolijskih komplikacija, koje mogu imati i smrtni ishod. Znatno poboljšanje u liječenju HIT-a, postignuto je primjenom direktnih inhibitora trombina u zamjenu za heparin, a laboratorijsko ispitivanje antiheparinskih protutijela znatno je unaprijedilo dijagnostiku HIT-a. Uvođenje smjernica za dijagnostičko-terapijski postupak za HIT ima znatan učinak na kvalitetu liječenja bolesnika. Godine 2008. u Republici Hrvatskoj (RH) pokrenut je niz aktivnosti u cilju uspostavljanja smjernica za HIT, temeljenih na britanskim preporukama za dijagnostiku i liječenje trombocitopenije izazvane heparinom iz 2006. godine. Tijekom 2008/09. godine uvedeni su novi testovi za antiheparinska protutijela, algoritam laboratorijskog ispitivanja i obrazac za kliničku procjenu HIT-a te izobrazba transfuziologa i kliničara. U siječnju 2010. godine na stručnom sastanku Hrvatskog društva za hematologiju i transfuzijsku medicinu (HDHTM), nakon evaluacije rezultata jednogodišnje primjene preporuka osnovana je radna skupina za donošenje smjernica HDHTM-a za HIT. Nakon usuglašavanja i javne rasprave smjernice su prihvaćene u svibnju 2011. godine.Heparin induced thrombocytopenia (HIT) is a serious complication of heparin administration. In the last decade, this clinical syndrome has come into the focus of interest, primarily because of the severe thromboembolic complications that may lead to lethal outcome. In addition, great improvements have been made in the treatment with direct thrombin inhibitors and in laboratory diagnosis of HIT. As guidelines for diagnostic and management of HIT upgrade the quality of patient treatment, activities for their development have been launched in the Republic of Croatia. Based on British Committee for Standards in Haematology (BCSH) recommendations on diagnostic and treatment of HIT from 2006, activities for the introduction of new assays for anti-heparin antibodies were launched in 2008 and 2009, including algorithm of laboratory testing for HIT, sheet for clinical assessment of HIT (4T score), and education of transfusiologists and clinicians. Upon evaluation of the results collected during one-year period, the Croatian Society of Haematology and Transfusion Medicine nominated a task force for the development of guidelines for HIT in January 2010. Following wide-ranging discussion, the guidelines were adopted in May 2011