Sanja Sakan

Vascular access for chronic hemodialysis in a patient with epidermolysis bullosa dystrophica Hallopeau-Siemens

Epidermolysis bullosa is a rare genetic hereditary disease characterized with mechanobullous dermatosis. Except cutaneous, these patients have various extracutaneous manifestations and some types of epidermolysis bullosa comprise almost all organ systems. Because of prolonged life span, chronic renal insufficiency has become an important cause of morbidity and death in these patients. Establishment of functional vascular dialysis access is a great challenge for both the doctors and the patients. Multidisciplinary approach is essential. We present a case of successful establishment of dialysis access via Tesio catheter in a young woman suffering from epidermolysis bullosa dystrophica Hallopeau‐Siemens and end‐stage renal disease. Since then, the Tesio catheter inserted via the right internal jugular vein has been the functional mean of dialysis. The patient was given the opportunity to lead a quality and active life in spite of disabling disease. Several cases of successful dialysis access establishment with dialysis catheters via central veins have been reported. We report the successful establishment of long‐term dialysis access via Tesio catheter and suggest this approach as ideal for these patients. This is the first report dealing with vascular access in this group of 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.

Consequence of Elevated Fibroblast Growth Factor 23 Levels in Acute Kidney Injury, Renal Recovery and Overall Survival in Intensive Care Unit Patients After Major Surgery: FGF23 and Acute Kidney Injury

The main goal of our study was to investigate the role of increased fibroblast growth factor 23 (FGF23) levels on renal recovery and overall survival. We conducted a prospective case‐control cohort study, which included 121 adult cases who developed AKI after major surgical procedures. The subjects were followed‐up until the last enrolled patient survived 180 days or until the time of death. Higher FGF23 levels positively correlated with serum creatinine levels (P < 0.05). Significantly higher number of patients without diuresis and with FGF23 ≤ 709 RU/mL survived when compared to patients without diuresis and with FGF23 ≥ 709 RU/mL (P < 0.001). FGF23 levels >709 RU/mL were a good predictive tool for overall mortality in a 6‐month period (P < 0.05). This is the first study to analyze the impact of FGF23 values on short‐term renal recovery and survival of patients with AKI after major surgery. The FGF23 increase related to AKI especially in more severe stages and in patients without diuresis is an independent risk factor for mortality.

Profilaksa poslijeoperacijske atrijske fibrilacije i resekcija pluća – naša iskustva sa 608 uzastopnih bolesnika

Postoperative atrial fibrillation is a common complication after lung resection. It is burdened by increased mortality and morbidity, prolonged hospitalization, and higher resource utilization in thoracic surgery patients. Therefore, some kind of pharmacological prophylaxis is recommended. In our patients, diltiazem, a calcium antagonist, is administered. We collected data on all 608 patients having undergone lung resection (no less than lobectomy) between November 2012 and May 2015. This period included patients having received diltiazem during their postoperative stay in our Intensive Care Unit and surgical ward, and those that did not receive it. Patients having had atrial fibrillation before the surgery and patients with cardiac pacemaker were excluded from the trial. Other patients were divided into three groups: patients with some kind of antiarrhythmic therapy before and continued after the surgery; patients with diltiazem prophylaxis; and patients without any antiarrhythmic prophylaxis. The data collected were statistically analyzed. We found no statistically significant difference in the incidence of postoperative atrial fibrillation among the groups (p<0.05).

Učinak inhalacijskih anestetika na akutno oštećenje bubrega

Acute kidney injury (AKI) is a serious complication associated with increased morbidity and mortality. Total incidence of AKI in hospitalized patients is 1%-5%. As many as 30% of these patients develop AKI in the perioperative period, which is associated with anesthesia and surgery. Despite scientific advances and improved surgery techniques, as well as treatment in intensive care units, no significant decrease in AKI incidence has been achieved. To change this outcome, it is important to identify patients at risk of AKI and prevent its occurrence. Correct selection of anesthetic drugs during general anesthesia, adjusted to the individual needs of patients, also influences the overall outcome of treatment. Nowadays, inhalational anesthetics are not considered nephrotoxic. The more so, inhalational anesthetics have a strong and direct protective effect on many organs through preconditioning and postconditioning. New studies have shown that sevoflurane diminishes ischemia/ reperfusion kidney injury and has an anti-inflammatory effect, thus having the potential to reduce the occurrence of AKI. Given the incidence of AKI in the perioperative period, as well as new findings about anesthetics, the issue of anesthetic selection during general anesthesia might be of crucial importance for the final outcome of treatment.

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