Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding ...during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
To investigate the efficacy and safety of non-invasive ventilation (NIV) with high PEEP levels application in patients with COVID-19-related acute respiratory distress syndrome (ARDS).
This is a ...retrospective cohort study with data collected from 95 patients who were administered NIV as part of their treatment in the COVID-19 intensive care unit (ICU) at University Hospital Centre Zagreb between October 2021 and February 2022. The definite outcome was NIV failure.
High PEEP NIV was applied in all 95 patients; 54 (56.84%) patients could be kept solely on NIV, while 41 (43.16%) patients required intubation. ICU mortality of patients solely on NIV was 3.70%, while total ICU mortality was 35.79%. The most significant difference in the dynamic of respiratory parameters between 2 patient groups was visible on Day 3 of ICU stay: By that day, patients kept solely on NIV required significantly lower PEEP levels and had better improvement in PaO
, P/F ratio, and HACOR score.
High PEEP applied by NIV was a safe option for the initial respiratory treatment of all patients, despite the severity of ARDS. For some patients, it was also shown to be the only necessary form of oxygen supplementation.
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.
Početkom pandemije COVID-19 zdravstveni sustavi pretrpjeli su ogroman pritisak radi velikog priljeva COVID bolesnika, a dodatnom opterećenju pridonio je manjak zdravstvenog osoblja te prijeteća ...nestašica respiratora. Također je zabilježena visoka smrtnost bolesnika na invazivnoj mehaničkoj ventilaciji. Zbog navedenih razloga pokrenula se rasprava o većem korištenju neinvazivne respiratorne potpore (engl. non-invasive respiratory support; NIRS), što obuhvaća kisik u visokim protocima apliciran putem nosnih kanila (engl. high-flow nasal cannula; HFNC), primjenu kontinuiranog pozitivnog tlaka u dišnim putevima (engl. continuous positive airway pressure; CPAP) i neinvazivnu ventilaciju (NIV). Nažalost, ne postoje standardizirane smjernice za odabir pacijenata za pojedini modalitet neinvazivne respiratorne potpore te je učinkovitost NIRS-a i dalje predmet brojnim raspravama i istraživanjima. Rezultati dosadašnjih studija sugeriraju da NIRS može poboljšati oksigenaciju te smanjiti potrebu za invazivnom mehaničkom ventilacijom i rizik od smrti kod COVID bolesnika. Međutim, učinkovitost i usporedbe pojedinih modaliteta neinvazivne respiratorne potpore istraživane su u svega nekoliko studija. Posljednje studije ukazuju na superiornost CPAP-a naspram NIV-a i HFNC-a, ali je rezultate potrebno interpretirati s oprezom pošto većina dosadašnjih studija o korištenju neinvazivnih modaliteta ventilacije kod COVID bolesnika ima značajna ograničenja i nedostatke. Tijekom neinvazivne respiratorne potpore potrebno je pažljivo monitorirati kliničko stanje pacijenta uz periodičku analizu plinova u arterijskoj krvi te procjenu HACOR skora (engl. heart rate, acidosis, consciousness, oxygenation, respiratry rate). Potrebno je na vrijeme prepoznati i reagirati na eventualne komplikacije neinvazivne respiratorne potpore. Iako se stopa plućne barotraume tijekom neinvazivne respiratorne potpore do sada smatrala zanemarivo niskom, istraživanja kod COVID bolesnika pokazala su puno višu incidenciju, što se na temelju dosadašnjih istraživanja pripisuje specifičnoj patofiziologiji virusa SARS-CoV-2. Proglašenje neinvazivne respiratorne potpore neuspješnom donosi se na temelju kliničkog prosuđivanja, a trebala bi biti individualizirana za svakog bolesnika i prepoznata na vrijeme jer se odgađanje intubacije i invazivne ventilacije pokazalo nezavisnim čimbenikom rizika za razvoj plućnih komplikacija i lošijeg ishoda.
At the beginning of the COVID-19 pandemic, healthcare systems suffered tremendous pressure due to the large influx of COVID-19 patients. The additional burden was contributed by the shortage of healthcare personnel and the threatening shortage of ventilators. High mortality of patients on invasive respiratory support was also recorded. For these reasons, a discussion has been initiated about the increased use of non-invasive respiratory support (NIRS), which includes high-flow oxygen delivered through nasal cannula (HFNC), the use of continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). Unfortunately, there are no standardized guidelines for selecting patients for a particular modality of non-invasive respiratory support, and the effectiveness of NIRS is still the subject of numerous debates and researches. The results of previous studies suggest that NIRS can improve oxygenation and reduce the need for invasive mechanical ventilation and the risk of death in COVID-19 patients. However, the effectiveness and comparisons of individual modalities of non-invasive respiratory support have been investigated in only a few studies. Recent studies indicate the superiority of CPAP compared to NIV and HFNC, but the results should be interpreted with caution since the most of the previous studies on the use of non-invasive ventilation modalities in COVID-19 patients have significant limitations and shortcomings. During non-invasive respiratory support, it is necessary to carefully monitor the patient's clinical condition with periodic analysis of gases in the arterial blood and evaluation of the HACOR score (heart rate, acidosis, consciousness, oxygenation, respiratry rate). It is necessary to recognize and react to possible complications of non-invasive respiratory support in time. Although the rate of pulmonary barotrauma during non-invasive respiratory support has so far been considered negligibly low, the research in COVID-19 patients has shown a much higher incidence, which, based on previous research, is attributed to the specific pathophysiology of the SARS-CoV-2 virus. Declaring non-invasive respiratory support unsuccessful is based on the clinical judgment, and should be individualized for each patient and recognized in time, as delay in intubation and invasive ventilation have been shown as independent risk factors for the development of pulmonary complications and a worse outcome.
Osmogodišnji dječak naručen je na elektivnu tonzilektomiju zbog ponavljanih upala srednjeg uha uzrokovanih hipertrofijom adenoida. Pacijent je imao otvoreni, tj. perzistentni arterijski duktus (engl. ...Persistent ductus arteriosus – PDA), čestu prirođenu srčanu grešku s očuvanom komunikacijom između aorte i plućne arterije. Kod pacijenta je postojao samo hemodinamski neznatan lijevo-desni pretok. Trenutačne smjernice za anesteziju pacijenata s lijevo-desnim pretokom uključuju: 1. održavanje ili smanjenje sustavnoga vaskularnog otpora
(SVR) kao hemodinamski cilj; 2. izbjegavanje smanjenja plućnoga vaskularnog otpora (PVR); 3.izbjegavanje hiperoksije i hipokarbije. Predoperacijska obrada uključivala je suradnju s pedijatrijskim kardiologom koji je napravio procjenu pacijentova srčanog statusa, uključujući ultrazvuk srca i elektrokardiogram (EKG). Tijek anestezije
protekao je bez neželjenih događaja. Nakon reverzije neuromuskularne blokade i ekstubacije pacijent je budan, hemodinamski stabilan i zadovoljavajućega respiratornog stanja prebačen u sobu za oporavak poslije anestezije. Preoksigenacija 100%-tnim kisikom prijeporna je u ovakvih pacijenata. Detaljna predoperacijska procjena srčanog
statusa i izbjegavanje povećanja protoka kroz otvorenu komunikaciju ključni su za dobar ishod u pacijenata s PDA-om.
Cilj ovog probnog projekta je evaluacija primjene INVOS oksimetrije za optimalizaciju anesteziološkog postupka kod operacija reperfuzije donjih ekstremiteta u bolesnika s perifernom arterijskom ...bolešću (PAB). Ispitanici: U probnom projektu evaluirana su 4 bolesnika s kritičnom ishemijom donjih ekstremiteta. Uz elektrodu za indikaciju cerebralne perfuzije (crSO2), drugu INVOS elektrodu za indikaciju periferne perfuzije, postavili smo distalno od vaskularne kleme (prSO2). Dobivene podatke smo koristili kao prediktore periferne perfuzije i nužnosti intervencije, a podatke smo usporedili s koncentracijom
laktata arterijske krvi. Rezultati: Početne prosječne crSO2 vrijednosti bile su 62,25 %, a prSO2 53,5 %. Prosječno trajanje arterijske okluzije bilo je 61 min. Pacijenti su primili u prosjeku 1275 mL kristaloida i 500 mL koloida. Najviše izmjerene vrijednosti laktata aterijske krvi bile su 0,7 mmol/L. Postoperacijski crSO2 iznosio je prosječno 73 %, a prSO2 69,75 %. Prosječna hospitalizacija trajala je 19,25 dana, s 30-dnevnim preživljavanjem od 100 %, bez potrebe reoperacije ili amputacije. Rasprava: Pretragom dostupne literature nismo pronašli sličnih kliničkih iskustava primjene optičke spektrometrije kao metode mjerenja intraoperacijske perfuzije ishemičnog ekstremiteta. Koristeći INVOS za poboljšanje perfuzije periferije koristili smo minimalnu vazoaktivnu potporu i restriktivnu bolusnu primjenu intravenskih tekućina uz zadovoljavajući klinički ishod.
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