Anaphylaxis is an unanticipated systemic hypersensitivity reaction 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 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 SW, 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.
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 > or = 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 microg/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 LiDCO plus system are reliable predictors of fluid responsiveness in mechanically ventilated septic patients in sinus cardiac rhythm.
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.
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.
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.
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.
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