The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm ...rupture.
We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability.
Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.
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.
: Differences in blood pressure can influence the risk of brain ischemia, perioperative complications, and postoperative neurocognitive function in patients undergoing carotid endarterectomy (CEA).
: ...In this single-center trial, patients scheduled for CEA under general anesthesia were randomized into an intervention group receiving near-infrared spectroscopy (NIRS)-guided blood pressure management during carotid cross-clamping and a control group receiving standard care. The primary endpoint was postoperative neurocognitive function assessed before surgery, on postoperative days 1 and 7, and eight weeks after surgery. Perioperative complications and cerebral autoregulatory capacity were secondary endpoints.
: Systolic blood pressure (
< 0.001) and norepinephrine doses (89 (54-122) vs. 147 (116-242) µg;
< 0.001) during carotid cross-clamping were lower in the intervention group. No group differences in postoperative neurocognitive function were observed. The rate of perioperative complications was lower in the intervention group than in the control group (3.3 vs. 26.7%,
= 0.03). The breath-holding index did not differ between groups.
: Postoperative neurocognitive function was comparable between CEA patients undergoing general anesthesia in whom arterial blood pressure during carotid cross-clamping was guided using NIRS and subjects receiving standard care. NIRS-guided, individualized arterial blood pressure management resulted in less vasopressor exposition and a lower rate of perioperative complications.
Objective: To explore differences in the health-related quality of life (HRQOL) of patients before and after cardiac surgery, to compare the results with norms of Croatian population and to correlate ...the results with values of EuroSCORE. Methods: This was a prospective observational study with repeated measurements using the Short Form SF-36 health survey before surgery and 1 year after discharge, to assess changes in quality of life. Results: A total number of 111 patients were included in the study. Seventy-one patients (64%) responded to second measurement of HRQOL 1 year after surgery. The mean age was 61 years, patients were predominantly male and the majority of patients were admitted for coronary artery bypass graft. The prevalence of comorbidity was relatively high. Preoperative mean values of study population were statistically lower than those representing Croatian general population in five out of eight health domains: physical functioning (p < 0.001), role physical (p < 0.001), bodily pain (p < 0.001), social functioning (p < 0.001) and mental health (p < 0.001). Data show significant improvement 1 year after discharge in four out of eight health domains: physical functioning (p = 0.02), role physical (p < 0.001), social functioning (p = 0.004) and mental health (p = 0.03). A subgroup of 30 patients with EuroSCORE ≥6 shows postdischarge improvements in the majority of scales: role physical (p < 0.001), bodily pain (p < 0.001), vitality (p = 0.03), social functioning (p = 0.01), role emotional (p = 0.03) and mental health (p = 0.002), and group with EuroSCORE <6 shows postdischarge improvement only in one health domain – role physical (p < 0.001). Conclusions: The health status of patients one year after hospital discharge shows a statistically significant improvement in half of the domains of physical and mental health compared with presurgery status. The high-risk group of patients (EuroSCORE ≥6) were likely to have significant improvement in greater number of health domains following surgery than the low- and medium-risk group (EuroSCORE <6).
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.
Introduction. Ceftazidime/avibactam, a novel beta-lactam antibiotic, demonstrates time-dependent bacterial killing; thus, new reports advocate its administration as a continuous infusion, as opposed ...to bolus or prolonged infusion application. Methods. Critically ill COVID-19 patients (n=10) superinfected with OXA-48-producing Klebsiella pneumoniae susceptible to ceftazidime/avibactam were treated with ceftazidime/avibactam as a continuous infusion for an average of 10 days. The treatment regimen included an initial loading dose, followed by a continuous infusion of ceftazidime/avibactam. These patients were immunocompromised because of severe COVID-19, treatment with corticosteroids, and some solid organ transplant recipients (n=2), all with high disease severity scores. Discussion. Considering the published literature to this date, this is the one of first reports describing the real-life results of using a continuous infusion of ceftazidime/avibactam in the treatment of OXA-48-producing K. pneumoniae superinfection in critically ill COVID-19 patients. Microbiological effectiveness of treatment, evidenced by negativization of microbiological samples, was achieved in eight cases (80%) overall, but in patients with sepsis and urinary tract infection, the cure rate was 100%. Conclusion. The reasons for the low treatment success rates in pneumonia caused by OXA-48-producing K. pneumoniae could be explained by the concurrent severe COVID-19 pneumonia.
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.
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