Višnja Majerić Kogler

Advantage of spontaneous breathing in patients with respiratory failure

The fact that different modalities of mechanical ventilation are associated with a number of serious side effects and risks and can influence the clinical outcome of patients, the various modes of mechanical ventilation have, over the past ten years, been the subject of a wide variety of scientific studies. Many of these modalities are designed for partial ventilatory support, which might reflect the complexity of the issue of patient’s ventilator interactions when spontaneous breathing activity is present, compared to controlled mechanical ventilation. Spontaneous breathing modes during mechanical ventilation may integrate intrinsic feedback mechanisms that should help prevent ventilatorinduced lung injury and improve synchrony between the ventilator and the patient’s demand. The improvements in pulmonary gas exchange, systemic blood flow, and oxygen supply to the tissue that have been observed when spontaneous breathing has been maintained during mechanical ventilation are reflected in the clinical improvement in the patient’ s condition. It is the aim of this article to review the effects of preserved spontaneous breathing activity during mechanical ventilation in patients with acute respiratory failure. VIŠNJA MAJERI KOGLER

Intraabdominal hypertension and abdominal compartment syndrome in the intensive care unit

Intraabdominal hypertension can induce a significant dysfunction of cardiovascular, respiratory, renal, and gastrointestinal and central nervous systems. Recently, a prospective multicenter epidemiological study concluded that the intraabdominal hypertension observed in intensive care units was associated with an increased risk of mortality in critically ill patients. In this review, we summarize current literature data concerning definitions and measurement of intraabdominal pressure and discuss the importance of intraabdominal hypertension in critically ill patients. We conclude that intraabdominal pressure should be taken into consideration along with other standard pressure measurements in critically ill patients. DANIELA BANDIĆ PAVLOVIĆ( ) • VIŠNJA MAJERIĆ KOGLER Department of Anesthesiology and Intensive Care Unit University Hospital Center Zagreb, Zagreb, Croatia e-mail: debandic@inet.hr Intraabdominal hypertension and measurement of the IAP IAP is measured directly by an intraperitoneal catheter or indirectly by a percutaneous inferior vena cava catheter, nasogastric catheter or urinary bladder catheter. Intravesicular pressure (IVP) measurement is now accepted as the gold standard because this method is simple, considerably accurate and widely available. In 1984 Kron et al. first described the method of IVP measurement in ACS after ruptured abdominal aortic aneurysm (3). IAP should be measured at end-expiration, in the supine position, after the bladder is firstly fully emptied, and then filled with 50 ml of saline. The degree of muscle relaxation as well as body weight has an affect on the measurement. Continuous IAP measurement using a nasogastric tube as well as continuous bladder irigation methods are now automated and they represent the most accurate methods in clinical practice. Different authors use different cut-off points for defining IAH (4,5,6,7). Sugrue et al. reported that even IAP of 10 mmHg (1mmHg = 1.36 cm H2O) might induce harm to several organ systems (6). Recently, at the World Congress on Abdominal Compartment Syndrome, the threshold for IAH was established as a value of 12 mmHg or greater in a minimum of three standardized measurements taken four to six hours apart (8). Four severity groups have been established on to basis of intraabdominal pressure values: grade 1, 12-15 mmHg; grade 2, 16-20 mmHg; grade 3, 21-25 mmHg; grade 4, greater than 25 mmHg (8). Intraabdominal hypertension induces organ system failure Current data concerning the IAH and ACS is rather large, but definitions are not clear. Malbrain et al. defined ACS as IAH greater than 20 mmHg in combination with at least one end-organ failure (2). Mc Nellis et al. defined ACS in surgical ICUs as IAP greater than 25 DANIELA BANDIĆ PAVLOVIĆ • VIŠNJA MAJERIĆ KOGLER REVIEW SIGNA VITAE 2006; 1(1): 13 15

Application of the procedural consolidation concept to surgical treatment of children with epidermolysis bullosa: a retrospective analysis

Aim To assess the efficacy of the procedural consolidation concept (PCC) at reducing the number of sessions of general anesthesia necessary for treating children with epidermolysis bullosa (EB). Methods We examined the records of children treated at Childrens Hospital of Zagreb between April 1999 and December 2007. Children treated before the introduction of PCC in January 2005 (n = 39) and after (n = 48) were analyzed in order to determine the effect of PCC on the occurrence of complications, days of hospitalization, and number of hospitalizations. Results During the study period, 53 patients underwent 220 sessions of general anesthesia for a total of 743 surgical interventions per session. Before the introduction of PCC (n = 39 patients, 83 sessions), the median number of interventions per session was 2 (range 1-5), and after the introduction of PCC (n = 48 patients, 137 sessions) it was 4 (range 3-7, P < 0.001). After the introduction of PCC, the median number of complications per anesthesia session increased from 2 (range 0-10) to 3 (range 0-10) (P = 0.027), but the median number of complications per surgical procedure decreased from 1 (range 0-10) to 0.6 (range 0-2.5) (P < 0.001). PCC lengthened each anesthesia session from a median of 65 minutes (range 35-655) to 95 minutes (range 50-405), (P < 0.001). Total length of hospitalization was similar before (median 1, range 1-4) and after (median 1, range 1-3) introduction of PCC (P = 0.169). The number of hospitalization days per procedure was 3 times lower after the introduction of PCC (median 0.3, range 0.2-3) than before (median 1, range 0.75-1.7) (P < 0.001). Conclusion PCC should be considered an option in the surgical treatment of children with EB.

Self-care of chronic musculoskeletal pain – experiences and attitudes of patients and health care providers

BackgroundSelf-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor’s supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.MethodsQualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.ResultsTopics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care.Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient’s contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.ConclusionPatients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.

Extravascular lung water index as an indicator of lung injury in septic patients

Introduction. Transpulmonary thermodilution using PiCCO (Pulse-induced Contour Cardiac Output) is a standard minimally invasive method used for haemodynamic monitoring. Objectives. The goal of this paper is to examine the correlation and dynamics of the ExtraVascular Lung Water Index (EVLWI) as an indicator of acute lung injury in septic patients who underwent major abdominal surgery. Two groups of patients were selected: the ones with ALI (Acute Lung Injury): ALI patient group, and the ones without ALI: non-ALI patient group. A correlation between EVLWI and other haemodynamic and respiratory data in both groups were analyzed.Materials and methods. The study included 48 patients. Throughout the seven-day period EVLWI, GEDVI (Global End-Diastolic Volume Index), ITBVI (IntraThoracic Blood Volume Index), CI (Cardiac Index), SVRI (Systemic Vascular Resistance Index) were measured in both groups using PiCCO monitoring over 8-hour intervals as well as heart rate, mean arterial pressure, serum albumin concentration, PaCO2 (arterial partial pressure of carbon dioxide), PaO2 (arterial partial pressure of oxygen), PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio, lung compliance, lung resistance and ScvO2 (central venous oxygen saturation). All patients were analgosedated, intubated, mechanically ventilated, in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and Sequential Organ Failure Assessment (SOFA) scores calculated. Ventilator settings and dosage of vasoactive drugs were kept constant during the study.Results. EVLWI was significantly higher in ALI patients group compared to non-ALI patients group. In patients with ALI group 11/22 patients died (50%), in the non-ALI patients group 6/26 patients died (23%). EVLWI was significantly higher in patients that died compared to ones who survived.Conclusion. EVLWI is a good indicator of early acute lung injury in surgical patients with sepsis.

Analgesia and sedation in hemodynamic unstable patient

Pain, restlessness, tension and delirium are almost always encountered while treating hemodynamic unstable critical patients in the intensive care units. Usually in critical patients, the evaluation of the nature and pain intensity (VAS scale) are often impossible. During the last 10 years intense nociceptor somatic and visceral post operative pain is believed to be the most crucial factor in the development of endocrine and neurohumoral disorders, within the postoperative period. Chronic post operative pain is appearing often (30%-40%), with great influence on the quality of patients life. The modern principal in treating acute pain is the use of multimodal balanced analgesia approach, which is individually catered with drug and dose for each patient. Modern systemic analgesia is understood to be the continuous use of opiates or opioids, titrated towards pain intensity, with a minimum number of complications even in hemodynamic unstable patients. The combined use of opioids with NSAID and paracetamol reduces the overall dosage of opioids by 20% 30% and therefore significantly contributes to hemodynamic and respiratory stability. Effective and safe epidural analgesia in hemodynamic unstable patients can be optimized by simultaneous use of various drugs with different mechanisms of action (local anaesthetic, opioid, adrenalin, ketamin). The accepted concept of analgosedation in critical patients is understood to be the use of short acting drugs (fentanyl, sufentanil, remifentanil, midazolam, propofol) in which drug dosage can be quickly adjusted in respect to the present clinical state of the patient. VIŠNJA MAJERIĆ KOGLER ( )•

Hemorrhagic shock as a complication of anticoagulant therapy following the mitral valve replacement

This report describes a case of the hemorrhagic shock in a patient on the anticoagulant therapy supplementing implanted mechanical prosthetic heart valve replacing the mitral valve. The association between hemorrhagic shock, mechanical prosthetic heart valve and anticoagulant therapy is briefly discussed.