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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

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Bedside detection of patient-ventilation asynchrony


Patient-ventilator asynchrony is common but under-recognized and under-reported. The frequency of PAV is reported around 23%, but up to 93% of patients have at least one episode of PVA. While sporadic asynchronies may have uncertain clinical impact, when they amount to more than 10% of the total breaths, PVA can increase the need for sedation and reduce sleep quality. In addition, they can impact on outcome by prolonging mechanical ventilation and increasing both ICU and hospital mortality.

The purpose of this review is threefold: 1) to characterise different types of patient-ventilator interaction; 2) to describe mechanisms leading to asynchrony; and 3) to describe ventilator modification to reduce patient-ventilation asynchrony.

Key words: ventilator waveforms, asynchronies, patient-ventilator interactions

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Role of echocardiography in the management of shock


Hemodynamic instability and inadequate cardiac performance is frequently found in critically ill patients. Transthoracic and transesophageal (in the case of inadequate visibility) echocardiography is increasingly used for non-invasive hemodynamic assessment and monitoring in the ICU setting. Using echocardiography, it is possible to assess preload, fluid responsiveness, systolic and diastolic cardiac function, and calculate cardiac output, intravascular and intra-cardiac pressures. It is the golden standard in the initial hemodynamic assessment and should be used as complementary tool in invasively monitored patients in the case of new circulatory or respiratory failure. Echocardiography is indispensable in the management of shock patients and is extremely powerful diagnostic role for the cardiac abnormalities (pericardial effusion and tamponade, acute cor pulmonale and acute or chronic valvular disorders) as a cause for hemodynamic instability. It is the most important and suitable method for assessment of right ventricular function, for diagnosis of septic cardiomyopathy and cardiac causes of weaning failure. Because of these advantages it should be routinely used by intensivists for hemodynamic assessment and monitoring and should be continuously available in the intensive care unit. The most important limitations of echocardiography are its inability to estimate adequacy of cardiac output and its intermittent nature. Therefore it should be used in rational combination with other complementary and continuous monitoring methods.

Key words: echocardiography, circulatory shock, critically ill patients

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Noninvasive ventilation in treatment of acute respiratory failure in ICU


In the last years noninvasive ventilation (NIV) is used increasingly worldwide in treatment of acute respiratory failure (ARF). The evidence strongly supports NIV use in patients with ARF, especially for chronic obstructive pulmonary disease (COPD) exacerbations and acute cardiogenic pulmonary edema. The efficacy of NIV depends on several factors like the experience of medical team, adequate selection of patient and interface and appropriate ventilator settings.

This is a retrospective analysis of patients with ARF treated by NIV in the medical intensive care unit (ICU), University Hospital Sveti Duh, between January 2015 and January 2016.

Analysis of statistical hospital data showed steady increments in NIV utilization from year 2011 (7%) to 2015 (15.7%). The mean age of studied patients was 69.8 years, 58.3% were male and 41.7% female. Four major causes for applying NIV were: COPD (41.7%), pneumonia (25%), acute cardiogenic pulmonary edema (19.4%) and other reasons (13.9%). Of 108 patients 93 (86.1%) were successfully treated with NIV and 15 (13.9%) were intubated.

A number of randomized clinical trials support the use of NIV in patients with ARF and beside the beneficial role in reducing patients symptoms it showed reduction in morbidity, mortality and length of stay in ICU. Failure rates of NIV still range from 25% to 40%, and optimization of NIV success rates requires careful patient selection and knowledge of proper application and monitoring techniques. If a patient fails to improve sufficiently, prompt endotracheal intubation should be performed without delay.

Key words: noninvasive ventilation, respiratory failure, chronic obstructive pulmonary disease, pulmonary edema

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Oral anticoagulants in patients with chronic kidney disease and atrial fibrillation


The aim of this study was to investigate the effects of new/direct oral anticoagulants (DOACs) on renal function parameters in chronic kidney disease patients with estimated glomerular filtration rate (eGFR) >30 mlmin-11.73m2.

A total of 40 chronic kidney disease patients with normal, mildly or moderately decreased renal function and non valvular atrial fibrillation were included (Group A) and were followed for 12 months. Dabigatran was started as 150 mg twice daily dose and rivaroxaban 20 mg once daily in patients with eGFR ≥ 50 mlmin-11.73m2. In patients with eGFR <50 and > 30 mlmin-11.73m2 dabigatran was started as 110 twice daily dose and rivaroxaban 15 mg once daily. Apixaban was started 2.5mg twice daily.

In group B there were 200 patients on warfarin for non valvular atrial fibrillation. Calculated HAS-BLED score was 2.8 (A) and 2.9 (B) and mean CHA2DS2VASc score was of 2.9 (A) and 3.1 (B). Changes in eGFR for up to12 months were evaluated. Treatment with warfarin caused a significant eGFR declined from 56±21 mlmin-11.73m2 to 51±19 (p<0.001), and 30% (62 of 200) of the patients had adverse events (31%). In patients on dabigatran and rivaroxaban, in both dosing regimens, and apixaban, eGFR (from 58±23 mlmin-11.73m2 to 58±19 mlmin-11.73m2 (p=0.01)) did not change, with significantly less adverse events (12% of patients). The results of our study suggest that therapy with new/direct oral anticoagulants (non-VKA oral anticoagulants) have a better bleeding risk profile and less decline in eGFR compared with vitamin K antagonists.

Key words: vitamin K antagonists, non-VKA oral anticoagulants, renal function

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Cardiac surgery and sepsis in postoperative period – our experience


The occurrence of sepsis after cardiac surgery is a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality revealed the need to improve treatment, aiming at patients’ better clinical outcome.

Patients that develop sepsis, regardless of the infectious focus and the subjacent disease, present high morbidity and mortality, which vary from 17% to 65%. The main predictors of infections in the postoperative period are: body mass index ≥40kg/m², haemodialysis in the preoperative period, pre-op cardiogenic shock, age ≥80 years, pre-op treatment with immunosuppressive agents, diabetes mellitus, ECC time ≥200 minutes, mechanical circulatory support, three or more revascularized vessels.

From January 2015 to December 2015, we studied 675 adult patients who underwent cardiac surgery. Prophylactic antibiotic therapy was prescribed and given according to our protocol, from the induction of anaesthesia to the first postoperative day.

Sepsis in the postoperative period was defined as evidence on infection associated with two or more criteria of systemic inflammatory response syndrome: body temperature >38°C or <36°C, leukocytes >12,000 cells/mm³, positive blood cultures, respiratory rate >20/min, heart rate >100/min.

Key words: sepsis, postoperative period, cardiac surgery

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