Acute kidney injury in perioperative settings (Views : 555 times)
Acute kidney injury is a clinical syndrome which represents relevant and serious perioperative complication. It is associated with increased patient morbidity, mortality, prolonged hospital stays, and not to mention greater healthcare costs. Yet, the patients who suffered from temporary acute kidney injury in the perioperative period, and regardless of the final outcome, usually complain afterwards about emotional distress, coupled with poor quality of life associated with loss of energy and limited normal physical activity. Therefore, the role of the physician to predict a kidney vulnerable patient in the perioperative period is a task of great importance, albeit not an easy one. The key management is risk stratification of the patient in conjunction with hemodynamic and oxygen optimization, in addition to avoiding nephrotoxic agents during the entire perioperative period.
Key words: acute kidney injury, perioperative, risk stratification
HES solutions in critical illness, trauma and perioperative period (Views : 491 times)
In the last few years, many studies and meta-analyses have demonstrated that hydroxyethyl starch (HES) solutions increase the risk of acute renal failure and mortality in critically ill patients. Some studies suggest complete avoidance of HES solutions in patients of all categories. On the other hand, recent studies and analyses suggest that HES solutions may be used in hypovolemic critically ill patients and in the perioperative setting. The main problem in everyday clinical practice and in a rational fluid management approach is that treatment with alternatives to HES solutions is not always pathophysiologically justified (crystalloids) or confirmed in randomised controlled trials (gelatins, albumins).
Key words: hydroxyethyl starches, critical illness, perioperative period
Transfusion in polytraumatised patients (Views : 419 times)
Background and Aim. Recent evidence indicates that surgical bleeding due to injured vessels and traumatic coagulopathy are the main reasons of uncontrolled haemorrhage in polytraumatized patients in the first 24 hours. The cornerstone of the treatment is adequate empiric early transfusion. The aim of our study was to survey the early transfusion in patients with major trauma and define the ratio of applied transfusion component in our hospital.
Patients and Methods: Patients with major trauma for a one year period, admitted to the Emergency Department of the Clinical Hospital Centre, Zagreb, were enrolled in our retrospective study. The following data were collected: age, sex, mechanism of injury, initial shock index (SI), initial Glasgow Coma Score (GCS), Injury severity score (ISS), and initial hemoglobin (Hb) and prothrombin time (PT). Intra-operative transfusion and transfusion within the first 24 hours of injury, Intensive care unit (ICU) stay and clinical outcome were assessed.
Results. 16 patients with major trauma were admitted. Eight patients received transfusions. Two patients received a massive transfusion. The transfusion ratio of Fresh frozen plasma (FFP) : Packed red blood cells (PRBC) : Platelets (PLT) during major trauma resuscitation was 1:1,5:1 in our study. One of the 16 patients died.
Conclusion. Early and aggressive resuscitation with transfusion blood products in major trauma patients within the first 24 hours with the FFP:PRBC:PLT ratio 1:1:1 is the key for prevention of trauma induced coagulopathy and its lethal consequences. Massive transfusion protocol for major trauma patients should be implemented in everyday practice.
Key words: abbreviated injury scales, blood component transfusion, injuries, polytrauma
Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients (Views : 401 times)
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.
Key words: intra-abdominal hypertension, arterial lactate concentration, sepsis
Inhalation plus intravenous colistin versus intravenous colistin alone for treatment of ventilator associated pneumonia (Views : 395 times)
In the setting of intensive care units the incidences of multi-drug resistant gram-negative (MDR-GN) pathogens causing ventilator associated pneumonia (VAP) has increased, leading clinicians to use colistin. Our aim was to assess outcomes associated with the use of inhalation and intravenous colisitn versus only intravenous colistin in patients with MDR-GN VAP. A retrospective, single centre study at University Hospital Centre, Zagreb. Patients were divided in two groups, according to their administration of antibiotics – inhalation and intravenous (INH+IV) administration for 8 patients or intravenous only (IV) administration for 23 patients.
The results showed that demographic and clinical characteristics and the gram negative pathogens isolated were similar between the two groups, except for K. pneumoniae, which was higher in the IV group. No statistically significant difference between the two groups were observed regarding intensive care unit mortality (P=0.951), sepsis (P=0.474), acute respiratory distress syndrome (P=0.548), length of ICU stay (P=0.686) and length of mechanical ventilation (P=0.858). A statistically significant difference was found regarding the eradication of pathogens in respiratory cultures (P= 0.018).
The addition of inhalation to intravenous colistin in MDR-GN VAP improves microbiologic outcome, but does not improve ICU mortality in these patients. Larger prospective trials are warranted to confirm the benefit of adjunctive inhalation colistin as a MDR-GN VAP therapy in the critically ill.
Key words: ventilator-associated pneumoni, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae