POSTOPERATIVE PULMONARY COMPLICATIONS AND ACUTE RESPIRATORY DISTRESS SYNDROME -BETTER PREVENT THEN TREAT.

In parallel with increasing number, duration and extensiveness of surgical interventions, postoperative pulmonary complications (PPC) and acute respiratory distress syndrome (ARDS) remain the major challenges for anesthesiologists and surgical ICU physicians. PPC and ARDS have multiple risk factors that should be recognized early and modifed within the appropriate "time window ". Today we possess reliable models (ARISCAT LIPS, EALI etc.) to predict the risk of non-infectious (hypoxemia, atelectases, pleuritis) and infectious PPC (postoperative pneumonia). The bundle of primaty and secondary prevention strategies is available and can be implemented both in the perioperative settings and in the ICU in patients at risk of PPC and ARDS. The prophylactic approach is realized as a bundle of strategies presented in "Checklist for Lung Injury Prevention" (CLIP). The bundle of preventive protective ventilation comprises low tidal volume (6-8 ml/kg predicted body weight), control of respiratory plateau and driving pressures, moderate positive end- expiratory pressure (PEEPS cm H20), and minimal safe level of inspired oxygen fraction. Pharmacological prevention ofARDS has shown quite satisfactory experimental results and needs further clinicql investigations.

[CONTINUOUS HEMOGLOBIN MONITORING USING PULSE CO-OXIMETRY IN CARDIAC SURGERY.]

THE AIM: To assess the accuracy ofcontinuous hemoglobin monitoring using pulse co-oximetry and revealfactors affecting the results of the measurements during early postoperative period in cardiac surgery. MATERIALS AND METHODS: 27 patients undergoing off-pump CABG and 16patients after elective complex (repair or replacement of two or more valves) or combined (valve and coronary artery) cardiac surgery requiring CPB were enrolled into a prospective observational study. Both groups received continuous hemoglobin monitoring using pulse co-oximetry (SpHb). During early postoperative period SpHb was compared with hemoglobin concentration in the arterial blood (Hbart). RESULTS: Wefoundpositive correlation between SpHb and Hb in both groups (rho =0,29, p < 0,05 u rho=0,34; p<0.005 respectively). The Bland-Altman analysis showed a bias ? limits of agreement (?I.96 SD) between the continuously measured hemoglobin and reference arterial blood hemoglobin concentration of -6,0 ? 41,0 g/l in the off-pump group and 7,7 k 31,0 g/l in the CPB group. CONCLUSIONS: Hemoglobin measurement using pulse co-oximetry does not provide acceptable accuracy during early postoperative period in cardiac surgery. Applicability of this technology is influenced by vascular tone, systemic and regional tissue hypoperfusion.

[VOLEMIC STATUS AND THE PHASIC APPROACH TO THE TREATMENT OF CRITICAL STATES--NEW OPPORTUNITES AND PROSPECTS].

Current guidelines suggest that an early and aggressive fluid therapy is the best rescue approach to restore and preserve cardiac index, organ function and decrease the risk of multiple organ failure in shock of various origin. However, escala- tion of fluid resuscitation is a double-edged sword often associated with reperfusion, glicocalyx injury, capillary leakage, delayed weight gain and heperhydration. The body of evidences demons trates that an excessive fluid load in ICUpatient with global increased permeability syndrome, and, particularly, in ARDS and acute kidney injury can be devastating, particularly when guided with central venous pressure. This important therapeutical conflict highlights the importance of the emerging concept of "phasic "fluid management and physiologic monitoring. The type and volume of the fluid should be thoroughly selected in accordance with the phase of shock, risk of impending organ dysfunction and individual co-morbidity. The phasic approach, along with individualized early and delayed goal-directed protocols might fasten the resolution of organ dysfunction, reduce the duration of shock and mechanical ventilation and improve the outcomes.

[Monitoring of intra-abdominal pressure and abdominal perfusion pressure in urgent abdominal surgery].

GOALS OF THE STUDY: To evaluate the changes in intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) during perioperative period in urgent abdominal surgery and to assess the relationship of these parameters with gas exchange and tissue perfusion. MATERIALS AND METHODS: Twenty-four patients undergoing emergency abdominal surgery were enrolled into a prospective observational study. We recorded IAP APP, mean arterial pressure, arterial and venous blood gases after induction of anesthesia, at the end of surgery, and 6, 12, 48 and 72 h postoperatively. LAP was measured by nasogastric tube using CiMON monitor (Pulsion Medical Systems, Germany). In addition, we studied the relationship of IAP and APP with blood gases parameters. RESULTS: We observed perioperative increase of IAP (> 12 mm Hg) in 75% of enrolled patients, tendency to postoperative rise of IAP and transient increase of arterial lactate at 6 h after surgery. APP remained within normal values. We found positive correlation of APP with PaO2/FiO2 and ScvO2 at 72 hours after surgery. CONCLUSION: Transient perioperative increase of IAP was observed in 75% patients undergoing urgent abdominal surgery; however in parallel with intensive care the abdominal perfusion pressure remained within normal values. Abdominal perfusion is related with arterial oxygenation and central venous saturation.

[Central venous blood oxygen saturation and venous to arterial PCO2 difference after combined heart valve surgery].

The aim of our study was to investigate the relationship between central venous oxygen saturation (ScvO2) and venous-to-arterial difference in PCO2 (Pv-aCO2) and their role in the assessment of balance between oxygen delivery and consumption after combined valve surgery. The prospective observation study included 38 adult patients with acquired valvular hear diseases, requiring surgical correction of two or more valves using cardiopulmonary bypass. All patients were divided into 2 groups according to the central value of central venous oxygen saturation (ScvO2): low ScvO2 (ScvO2 < 70%) and high ScvO2 (ScvO2 > 70%). In both groups blood gases, Pv-aCO2, lactate concentration, hemodynamic parameters, cardiac index, oxygen delivery and oxygen consumption were assessed. During the postoperative period there was a decrease of ScvO2 < 70% in 26% of patients which was accompanied by increased Pv-aCO2 > 5 mmHg and by risen oxygen consumption. We observed a moderate correlation between ScvO2 and Pv-aCO2 during the early postoperative period: at the end of surgery, 6 and 12 hours after it (rho = -0.53; -0.62 and -0.43 respectively, n = 38, p < 0.01). The changes in ScvO2 and Pv-aCO2 regressed after 24 hours in ICU. Thus, decreased ScvO2 and increased Pv-aCO2 after combined valve surgery are related and reflect the rise in oxygen consumption.