Coagulation disorders in critically ill patients presenting with bleeding can be multicausal. The drugs applied can interfere and impair the coagulation cascade. Point-of-care (POC) coagulation ...assays may resolve difficult therapeutic situations in critical illness. We report on a 73-year-old critically ill male patient with massive hematuria after bladder lithotripsy. The patient was on low molecular weight heparin therapy due to recent pulmonary embolism. He was subjected to repeated surgical hemostasis which was ineffective despite massive transfusion protocol and normal standard coagulation profile. Additional POC coagulation assays were obtained and were indicative of platelet dysfunction. We revised his medical therapy and suspected the possible drug influence on platelet aggregation. After discontinuation of target drug, platelet aggregation increased whereas hematuria stopped. Coagulation disorders in intensive care unit patients are often multifactorial. Standard laboratory tests are unreliable in complex refractory bleeding and may result in inappropriate therapeutic decisions. Stepwise approach with assessment of clinical parameters, present therapy, and a combination of POC coagulation tests is the key to optimal therapeutic management.Coagulation disorders in critically ill patients presenting with bleeding can be multicausal. The drugs applied can interfere and impair the coagulation cascade. Point-of-care (POC) coagulation assays may resolve difficult therapeutic situations in critical illness. We report on a 73-year-old critically ill male patient with massive hematuria after bladder lithotripsy. The patient was on low molecular weight heparin therapy due to recent pulmonary embolism. He was subjected to repeated surgical hemostasis which was ineffective despite massive transfusion protocol and normal standard coagulation profile. Additional POC coagulation assays were obtained and were indicative of platelet dysfunction. We revised his medical therapy and suspected the possible drug influence on platelet aggregation. After discontinuation of target drug, platelet aggregation increased whereas hematuria stopped. Coagulation disorders in intensive care unit patients are often multifactorial. Standard laboratory tests are unreliable in complex refractory bleeding and may result in inappropriate therapeutic decisions. Stepwise approach with assessment of clinical parameters, present therapy, and a combination of POC coagulation tests is the key to optimal therapeutic management.
Most studies examining tramadol metabolism have been carried out in non-surgical patients and with oral tramadol. The aim of this study was 1) to measure concentrations of tramadol,
-demethyltramadol ...(ODT), and
-demethyltramadol (NDT) in the surgical patients admitted to the intensive care unit (ICU) within the first 24 postoperative hours after intravenous application of tramadol, and 2) to examine the effect of systemic inflammation on tramadol metabolism and postoperative pain.
A prospective observational study was carried out in the surgical ICU in the tertiary hospital. In the group of 47 subsequent patients undergoing major abdominal surgery, pre-operative blood samples were taken for
polymorphism analysis. Systemic inflammation was assessed based on laboratory and clinical indicators. All patients received 100 mg of tramadol intravenously every 6 h during the first postoperative day. Postoperative pain was assessed before and 30 min after tramadol injections. Tramadol, ODT, and NDT concentrations were determined by high-performance liquid chromatography.
analysis revealed 2 poor (PM), 22 intermediate (IM), 22 extensive (EM), and 1 ultrafast metabolizer. After a dose of 100 mg of tramadol, t
of 4.8 (3.2-7.6) h was observed. There were no differences in tramadol concentration among metabolic phenotypes. The area under the concentration-time curve at the first dose interval (AUC
) of tramadol was 1,200 (917.9-1944.4) μg ×h ×L
. NDT concentrations in UM were below the limit of quantification until the second dose of tramadol was administrated, while PM had higher NDT concentrations compared to EM and IM. ODT concentrations were higher in EM, compared to IM and PM. ODT AUC
was 229.6 (137.7-326.2) μg ×h ×L
and 95.5 (49.1-204.3) μg ×h ×L
in EM and IM, respectively (
= 0.004). Preoperative cholinesterase activity (ChE) of ≤4244 U L
was a cut-off value for a prediction of systemic inflammation in an early postoperative period. NDT AUC
were significantly higher in patients with low ChE compared with normal ChE patients (
= 0.006). Pain measurements have confirmed that sufficient pain control was achieved in all patients after the second tramadol dose, except in the PM.
polymorphism is a major factor in
-demethylation, while systemic inflammation accompanied by low ChE has an important role in the
-demethylation of tramadol in postoperative patients. Concentrations of tramadol, ODT, and NDT are lower in surgical patients than previously reported in non-surgical patients. Clinical Trial Registration: ClinicalTrials.gov, NCT04004481.
Tramadol is a commonly used analgesic in intensive care units (ICUs) for acute postoperative pain. Conversion of tramadol into active metabolites may be impaired in inflammatory states. ...Catechol-O-methyltransferase may influence pain. The aim of the study was to examine differences in the analgesic effect of tramadol between ICU patients with and without signs of systemic inflammation. Forty-three patients were admitted to ICU after a major abdominal surgery. The patients received a dose of 100 mg of tramadol intravenously every 6 hours during the first 24 hours after surgical procedure. Pain scores were measured by the Numeric Rating Scale before and 30 minutes after tramadol administration in awake patients. Systemic inflammation was considered when at least two of the following postoperative parameters were present in the first 24 hours of ICU admission: fever or hypothermia, tachycardia, pCO.sub.2 <4.3 kPa, white blood cells >12000/mm (3) or <4000/mm.sup.3, or preoperative value of C-reactive protein (CRP) >50 mg/L or/and procalcitonin (PCT) >0.5 mg/L. Catechol-O-methyltransferase was analyzed postoperatively. Fifteen (34.8%) patients met the criteria for systemic inflammation. Tramadol was proven to be an effective analgesic for the treatment of postoperative pain regardless of the presence of systemic inflammation (p<0.05). Lower perception of pain before tramadol application was observed in patients with systemic inflammation, but the difference was not significant. A negative correlation was observed between the preoperative values of CRP and PCT and the analgesic effect of tramadol assessed at the second measurement point (r=-0.3S8, p=0.03, and r=-0.364, p=0.02, respectively). Catechol-O-methyltransferase variants were not in correlation with pain and opioid consumption. Based on our findings, tramadol is effective in lowering pain scores after major abdominal surgery irrespective of the presence of systemic inflammation. Key words: Analgesia; Critical care; Systemic inflammatory response; Catechol-O-methyltransferase; Tramadol
Postoperative cognitive impairment is a common disorder after major surgery. Advances in medicine and treatment have resulted in an increasingly ageing population undergoing major surgical ...procedures. Since age is the most important risk factor for postoperative cognitive decline, it is not surprising that impairment of cognitive functions after surgery was recorded in almost a third of elderly patients. Postoperative cognitive dysfunction is part of the spectrum of postoperative cognitive impairment and researchers often confuse it with postoperative delirium and delayed neurocognitive recovery. This is the cause of great differences in the results of research that is focused on the incidence and possible prevention of postoperative cognitive dysfunction. In this review, we focused on current recommendations for a uniform nomenclature of postoperative cognitive impairment and diagnosis of postoperative cognitive dysfunction, the presumed pathophysiology of postoperative cognitive dysfunction and recommendations for its treatment and possible prevention strategies.
To investigate the possible effect of postoperatively applied analgesics-epidurally applied levobupivacaine or intravenously applied morphine-on systemic inflammatory response and plasma ...concentration of interleukin (IL)-6 and to determine whether the intensity of inflammatory response is related to postoperative cognitive dysfunction (POCD).
This is a randomized, prospective, controlled study in an academic hospital. Patients were 65 years and older scheduled for femoral fracture fixation from July 2016 to September 2017. Inflammatory response was assessed by leukocytes, neutrophils, C reactive protein (CRP) and fibrinogen levels in four blood samples (before anesthesia, 24 hours, 72 hours and 120 hours postoperatively) and IL-6 concentration from three blood samples (before anesthesia, 24 hours and 72 hours postoperatively). Cognitive function was assessed using the Mini-Mental State Examination preoperatively, from the first to the fifth postoperative day and on the day of discharge.
The study population included 70 patients, 35 in each group. The incidence of POCD was significantly lower in the levobupivacaine group (9%) than in the morphine group (31%) (p=0.03). CRP was significantly lower in the levobupivacaine group 72 hours (p=0.03) and 120 hours (p=0.04) after surgery. IL-6 values were significantly lower in the levobupivacaine group 72 hours after surgery (p=0.02). The only predictor of POCD in all patients was the level of IL-6 72 hours after surgery (p=0.03).
There is a statistically significant association between use of epidural levobupivacaine and a reduction in some inflammatory markers. Postoperative patient-controlled epidural analgesia reduces the incidence of POCD compared with intravenous morphine analgesia in the studied population.
NCT02848599.
Cilj istraživanja: Usporediti stavove intenzivista Kliničkog bolničkog centra Osijek o kraju života u jedinicama intenzivnog liječenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje ...se sastojalo od dva dijela: provođenje anonimne ankete među liječnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolničkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da većina liječnika nije primjenjivala smjernice za unaprijeđenje palijativne skrbi u JIL-u te da postoje dileme oko etičnosti ograničenja mjera umjetnog održavanja života. Kao glavni razlozi neprovođenja smjernica bili su identificirani nedostatak pravne zaštite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je značajno velik broj smrti nakon neuspješne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovođenju KPR-a i izostavljanju određene mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograničavanju mjera i postupaka umjetnog održavanja života, većina liječnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. Zaključak: Navedeni rezultati ukazuju na potrebu za poboljšanjem postupanja u donošenju odluka o kraju života u JIL-u.
Aim Preoperative comorbidity may significantly influence theconduction of anesthesia and patients’ outcome. The aim of thisstudy was to compare a number of anesthetic interventions and theuse of ...non-anesthetic drugs in hypertensive and non-hypertensivepatients during general anesthesia for moderately invasive surgery.Methods A total number of 88 elective hypertensive (n = 44) andnon-hypertensive (n = 44) breast cancer patients were enrolled inthe prospective study. Midazolam and infusion of normal salinewere given before anesthesia. Etomidate, rocuronium, fentanyl,and sevoflurane up to the 1 MAC were used for the maintenanceof anesthesia. Mean arterial pressure (MAP), pulse, core temperatureand intraoperative use of all drugs were recorded. MAPwas maintained by sevoflurane and infusion replacement. Urapidiland ethylephrine were given if MAP differed > or <30% ofbaseline, and atropine if heart rate <50 beats min-1. A statisticalanalysis was made using chi-square and Mann-Whitney tests.Results The highest MAP was 133±19.3 in hypertensive and 122±16.5mmHg in the non-hypertensive patients (p<0.05). Hypertensive patientsrequired more anesthetic balancing (42 vs. 23 interventions),more urapidil for intraoperative hypertension (13/44 vs. 2/44, p<0.05) and had more intraoperative hypotensive episodes (23 vs. 12;ns, p> 0.05). Intraoperative bradycardia (11/44 vs.7/44) and atropineapplications (16 vs. 9, ns, p> 0.05) were similar in two groups.Conclusion Hypertensive patients required more anesthetic interventionsand had higher consumption of vasoactive drugs duringanesthesia for breast cancer surgery, suggesting their hemodynamicinstability possibly related to the hypertension.
Sindrom kratkog crijeva očituje se malapsorpcijom koja je posljedica opsežne resekcije crijeva. Duljina crijeva preostaloga nakon kirurške resekcije smatra se glavnom odrednicom ishoda u tih ...bolesnika. Liječenje sindroma složeno je i nalaže multidisciplinarni pristup radi smanjenja morbiditeta i mortaliteta. Ovaj prikaz opisuje 60-godišnju bolesnicu koja je podvrgnuta multiplim resekcijama crijeva, što je rezultiralo preostalim tankim crijevom duljine 30 cm postduodenalno i terminalnom jejunostomom. Njezin boravak u jedinici intenzivnog liječenja zakomplicirao se zbog razvoja respiratornog zatajenja, bilateralne pneumonije i sepse. Pacijentica je mehanički ventilirana i liječena antimikrobnim lijekovima u skladu s rezultatima mikrobioloških pretraga i antibiogramom. Inicijalno je započeta potpuna parenteralna prehrana, dok se enteralna prehrana uvodila postupno. U liječenju bolesnice sudjelovao je multidisciplinarni tim sastavljen od anesteziologa, kirurga i gastroenterologa. Nakon četiri mjeseca bolničkog liječenja pacijentica je otpuštena kući opremljena tuneliranim središnjim venskim kateterom, a parenteralna je prehrana nastavljena u kućnim uvjetima u kombinaciji s peroralnim hranjenjem.
Kontinuirane metode bubrežnoga nadomjesnog liječenja posljednjih godina imaju sve veću ulogu pri zbrinjavanju bolesnika u jedinicama intenzivnog liječenja. Prednosti koje one pružaju u odnosu prema
...konvencionalnim, intermitentnim metodama pogoduju kritično oboljelima, zbog čega je ova metoda vrlo privlačna pri izboru terapijskog pristupa u jedinicama intenzivnog liječenja. Primjer je klinički prikaz dotad zdravoga četrdesetšestogodišnjeg muškarca koji je primljen u jedinicu intenzivnog liječenja zbog iznenadno nastalog poremećaja stanja svijesti, respiratorne insuficijencije, cirkulacijske nestabilnosti, rabdomiolize, anurije i akutnoga bubrežnog oštećenja nepoznatog uzroka. Bolesnik je mehanički ventiliran, volumno resuscitiran,
nalažući cirkulacijsku potporu vazopresorima. Unatoč inicijalno poduzetim mjerama intenzivnog liječenja nije došlo do oporavka diureze i hemodinamske stabilizacije uz daljnje pogoršanje stanja. Zbog perzistirajuće hiperkalemije opasne za život, metaboličke acidoze, uremije i rabdomiolize započeti su kontinuirano bubrežno nadomjesno
liječenje (engl. Continuous renal replacement therapy – CRRT), uz istodobno pružanje potpore narušenim organskim sustavima, i traganje za mogućim uzrokom prezentirane kliničke slike. Nakon tjedan dana kontinuirane potpore narušenoj bubrežnoj funkciji došlo je do oporavka stanja svijesti, hemodinamske stabilizacije, odvajanja od strojne ventilacije i oporavka diureze uz normalizaciju bubrežne funkcije. Ciljanom toksikološkom analizom urina potvrđeno je da su anabolički steroidi koje je bolesnik uzimao mogući uzrok rabdomiolize i bubrežnog oštećenja. Bolesnik je desetog dana otpušten iz jedinice intenzivnog liječenja u dobrom općem stanju i uredne bubrežne funkcije. Kontinuirane metode bubrežnoga nadomjesnog liječenja učinkovit su način zbrinjavanja akutnoga bubrežnog oštećenja u kritično oboljelih zbog nastaloga multiorganskog zatajenja različite etiogeneze.
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