Robert Baronica

CVP vs. dynamic hemodynamic parameters as preload indicators in hemodynamically unstable patients after major surgery

Introduction. Adequate circulating blood volume is essential for the good outcome in postoperative patients. Therefore, the primary resuscitation question is how to assess the circulating volume. The aim of this study was to compare the central venous pressure (CVP) and dynamic LIDCO parameters as markers indicating preload in surgical patients. Materials and Methods. This prospective study included 24 patients hospitalized after major surgery at the surgical intensive care unit of the University hospital Zagreb, Croatia. The patients were mechanically ventilated, without spontaneous breathing attempts and in sinus rhythm. Patients were divided into 2 groups, hemodynamically stable and hemodynamically unstable. The CVP was measured as a static parameter while the stroke volume variation (SVV) and pulse pressure variation (PPV) were measured as the dynamic parameters. Results. Study groups were comparable in terms of gender, age and body mass index. The difference in the CVP between the hemodynamically stable (13,2±3,74 mmHg) and hemodynamically unstable group of patients (10,1±5,6 mmHg) was statistically insignificant (p=0,144). Differences in SVV (10,2±6,48% in stable compared to 18,8±7,04% in unstable group) and PPV (11,5±6,65% in stable compared to 18±6,32% in unstable group) were both statistically significant with p values of 0,005 and 0,022 respectively. Conclusion. The study confirmed the inability of CVP to provide valid assessment of the preload as a reason for hemodynamic instability in comparison to dynamic LiDCOTMplus system parameters in mechanically ventilated major surgical patients.

Respiratory arrest due to hematoma caused by thyreocervical trunk branch laceration and confluence of sinuses perforation.

Introduction Central venous catheterization plays an important role in the treatment of emergency patients who require renal replacement therapy. Emergency patients with end-stage renal disease are at high risk for development of complications because of coagulation disorders, tissue, and organ changes due to uremia, anatomic variations, and obstruction of the large central veins. Complications associated with catheter placement can be mechanical, infectious, and thrombotic, and may occur during or following insertion of central venous catheterization which is a life-saving procedure for patients. Case presentation We report a case of respiratory arrest in a 76-year-old woman suffering from end-stage renal disease for 14 years, because of large soft tissue subcutaneous hematoma in the right upper thoracic outlet. The rapid development of hematoma was a consequence of arterial bleeding from the branch of the thyreocervical trunk. Laceration of the thyreocervical trunk branch during central venous catheterization is a rare complication. Later diagnostic images revealed catheter perforation of confluence of sinuses which also complicated this case. We briefly discuss signs, symptoms, and management of the patient. Conclusion Although arterial puncture of the carotid artery during the Seldinger technique is well-known life-threatening complication which can be recognized by light red pulsatile blood during aspiration, smaller arteries such as the thyreocervical trunk branch can be punctured during the procedure and lead to serious complications.

Anesthesia techniques for carotid endarterectomy

Stroke is one of the leading causes of death in the modern countries. Mainstay treatment for stroke prevention is carotid endarterectomy (CEA). Patients scheduled for surgery often have many associate systemic illnesses that pose a risk of perioperative cardiac and neurological complications. Detailed preoperative evaluation of neurological and cardiac function with optimization of the systemic illnesses therapy is obligatory. Ideal anesthesiology technique should provide adequate analgesia, minimal stress response, optimal brain perfusion and oxygenation, optimal hemodynamic and myocardial oxygen balance while assuring calm and relaxed patients with good surgical comfort. Both regional anesthesia and general anesthesia have some advantages and drawbacks. Regarding to cerebral and myocardial ischemia and adverse outcome after CEA, especially in high risk patients, today still it is not clear which anesthesia technique is preferred for CEA. Greatest risk in the early postoperative period is new neurological deficit caused by cerebral ischemia end myocardial infarction caused with hemodynamic instability and therefore CEA patients are placed in the Intensive Care Unit for at least six or more hours where they are monitored for neurological and hemodynamic complications. DINKO TONKOVI ( ) University of Zagreb Department of Anesthesiology Reanimatology and Intensive Care University Hospital “Sv. Duh” Sv. Duh 64, 10 000 Zagreb, Croatia