Near-Infrared Spectroscopy-Guided, Individualized Arterial Blood Pressure Management for Carotid Endarterectomy under General Anesthesia: A Randomized, Controlled Trial.

Background: Differences in blood pressure can influence the risk of brain ischemia, perioperative complications, and postoperative neurocognitive function in patients undergoing carotid endarterectomy (CEA). Methods: In this single-center trial, patients scheduled for CEA under general anesthesia were randomized into an intervention group receiving near-infrared spectroscopy (NIRS)-guided blood pressure management during carotid cross-clamping and a control group receiving standard care. The primary endpoint was postoperative neurocognitive function assessed before surgery, on postoperative days 1 and 7, and eight weeks after surgery. Perioperative complications and cerebral autoregulatory capacity were secondary endpoints. Results: Systolic blood pressure (p < 0.001) and norepinephrine doses (89 (54-122) vs. 147 (116-242) µg; p < 0.001) during carotid cross-clamping were lower in the intervention group. No group differences in postoperative neurocognitive function were observed. The rate of perioperative complications was lower in the intervention group than in the control group (3.3 vs. 26.7%, p = 0.03). The breath-holding index did not differ between groups. Conclusions: Postoperative neurocognitive function was comparable between CEA patients undergoing general anesthesia in whom arterial blood pressure during carotid cross-clamping was guided using NIRS and subjects receiving standard care. NIRS-guided, individualized arterial blood pressure management resulted in less vasopressor exposition and a lower rate of perioperative complications.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease.

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.

The Limits of Acute Anemia.

For many years, physicians' approach to the transfusion of allogeneic red blood cells (RBC) was not individualized. It was accepted that a hemoglobin concentration (Hb) of less than 10 g/dL was a general transfusion threshold and the majority of patients were transfused immediately. In recent years, there has been increasing evidence that even significantly lower hemoglobin concentrations can be survived in the short term without sequelae. This somehow contradicts the observation that moderate or mild anemia is associated with relevant long-term morbidity and mortality. To resolve this apparent contradiction, it must be recognized that we have to avoid acute anemia or treat it by alternative methods. The aim of this article is to describe the physiological limits of acute anemia, match these considerations with clinical realities, and then present "patient blood management" (PBM) as the therapeutic concept that can prevent both anemia and unnecessary transfusion of RBC concentrates in a clinical context, especially in Intensive Care Units (ICU). This treatment concept may prove to be the key to high-quality patient care in the ICU setting in the future.

REGIONAL ANESTHESIA FOR NEUROSURGERY.

During neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery.

[Stroke volume and pulse pressure variation are good predictors of fluid responsiveness in sepsis patients]. / Varijacija udarnog volumena i tlaka pulsa dobri su pokazatelji hemodinamskog odgovora na nadoknadu volumena u sepsi.

UNLABELLED: Stroke volume variation (SVV) and pulse pressure variation (PPV) are dynamic preload indicators. Specific interactions of the cardiovascular system and lungs under mechanical ventilation cause cyclic variations of SVV and PPV. Real time measurement of SVV and PPV by arterial pulse contour analysis is useful to predict volume responsiveness in septic patients. Results of a prospective, 2-year observational study conducted at Department of Anesthesiology, Resuscitation and Intensive Care, Zagreb University Hospital Center, are presented. Volume responders and non-responders were defined. Correlation between SW, PPV, stroke volume index (SVI) and other hemodynamic data in septic patients was analyzed. The study was conducted from September 2009 to December 2011. Sepsis group included 46 patients (22 male, age 46 +/- 6, APACHE II score 26 +/- 5, and 24 female, age 41 +/- 6, APACHE II score 24 +/- 4) undergoing major abdominal surgery with clinically and laboratory confirmed sepsis, defined according to the international criteria. EXCLUSION CRITERIA: patients with LVEF < 45%, atrial fibrillation, aortic insufficiency, pulmonary edema, children, pregnant women, patients on lithium therapy, and patients who did not sign informed consent. Septic patients were divided into volume responders (VR) and volume non-responders (VNR). Responders were defined as patients with an increase in SVI of > or = 15% after fluid loading. SVV, PPV and SVI were assessed by arterial pulse contour analysis using the LiDCOTM plus system continuously for 8 hours. Simultaneously, cardiac index (CI), mean arterial pressure (MAP), heart rate (HR), oxygen delivery (DO2), oxygen consumption (VO2) and central venous oxygen saturation (ScvO2) were assessed. Hemodynamic data were recorded before and after fluid administration of 500 mL of 6% hydroxyethyl starch over 30 min. All patients were sedated with midazolam (0.05-0.15 mg/kg/h). Analgesia was maintained with sufentanil (0.2-0.6 microg/kg). All patients were intubated and mechanically ventilated (IPPV; FiO2 0.4; TV 7 mL/kg; PEEP 5 cm H2O) in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and SOFA scores calculated. Ventilator settings and dosage of vasoactive drugs were all kept constant during the study. Data were compared using Student's t-test. Correlation was estimated using Pearson's coefficient. The level of statistical significance was set at P < 0.05. Positive response to fluid loading was present in 26 (57.4%) patients. Baseline SVV correlated with baseline PPV (r = 0.92, P < 0.001). SVV and PPV were significantly higher in responders than in nonresponders. SVV: 14.4 +/- 3.3 vs. 7.1 +/- 3.1; P < 0.001. PPV: 15.2 +/- 4.1 vs. 7.4 +/- 4.5; P < 0.001. Other hemodynamic parameters measured were statistically different between the two groups. Only DO2 values showed no statistical significance between the responders and non-responders. There was no difference between the area under receiver operating characteristic curves of SVV (0.96; 95% confidence interval 0.859-0.996) and PPV (1.000; 95% confidence interval 0.93-1.000). Optimal threshold value for discrimination between VR and VNR was 10% for SVV (sensitivity 96.15%, specificity 100%) and 12% for PPV (sensitivity 100%, specificity 100%). In conclusion, SVV and PPV measured by LiDCO plus system are reliable predictors of fluid responsiveness in mechanically ventilated septic patients in sinus cardiac rhythm.

[Prevention and treatment of intensive care unit delirium]. / Prevencija i terapija bolesnika s delirijem u jedinici intenzivnog lijecenja.

Delirium is a common problem in intensive care patients, frequently underdiagnosed and resulting in prolonged hospital stay and a high risk of morbidity and mortality. On the other hand, reversibility of the condition points to the importance of prevention, early diagnosis and immediate therapy. Management strategy is directed to nonpharmacological interventions as preventive measures and pharmacological treatment, which includes typical and atypical neuroleptics. Delirium management includes haloperidol as the first line medication, but also olanzapine and risperidone as atypical neuroleptics. Benzodiazepines are used in delirium caused by alcohol withdrawal.

[Pathophysiology of delirium]. / Patofiziologija delirija.

Today's understanding of the pathophysiological mechanisms of delirium is still limited, but there are several promising hypotheses. It is believed that biomarkers sensitive to death of neurons or glial cells indicate delirium. Several neurotransmitters are considered to be involved in the state of delirium, with greatest emphasis on acetylcholine and dopamine acting in opposite ways; acetylcholine reduces, while dopamine increases neuron excitability. Other neurotransmitters that probably play a role in the pathogenesis of delirium are GABA, glutamate and monoamines. Sepsis leading to systemic inflammatory response syndrome often presents with delirium and perhaps is the most common causal factor for delirium in intensive care unit; sedatives and analgesics are also common iatrogenic risk factors. Patients receiving benzodiazepines are more likely to have postoperative delirium than those who do not. Postoperative cognitive changes are more common in older than in younger patients, and they can be categorized as postoperative delirium, postoperative cognitive dysfunction and dementia. The mechanisms responsible for postoperative cognitive changes are not fully understood, but it is certain that they are multifactorial. Risk factors may be associated with patient characteristics, type of surgery and type of anesthesia.

[Postoperative mental disorders in cardiovascular surgery]. / Poslijeoperacijski poremecaji mentalnih funkcija u kardiovaskularnoj kirurgiji.

Postoperative mental disorders are a common complication of cardiovascular surgery, with serious consequences. The main types of postoperative mental disorders include postoperative delirium and postoperative cognitive dysfunction. Their incidence ranges up to 15%-80%. Postoperative mental disorders may be reversible and irreversible. Although reversible in most cases, postoperative mental disorders are associated with increased mortality, morbidity and increasing costs of treatment. The treatment is usually symptomatic and may be associated with dangerous side effects. Safer and more effective is preventive action. Preoperative preventive action need to recognize, avoid and optimize risk factors. Intraoperative prevention involves maintaining optimal oxygenation of the brain during cardiovascular surgery. For postoperative prevention, multimodal approach is applied. It includes early extubation, early enteral nutrition, early mobilization, regular evaluation of cognitive function, activation of cognitive function and optimal analgesia, which requires teamwork of medical staff who care for patients. Combining all these methods can show promising results in reducing the incidence of postoperative mental disorders as a complication in cardiovascular surgery.

[Perioperative disorders of mental functions]. / Perioperacijski poremecaji mentalnih funkcija.

Mental disorders are characterized by disturbances of thought, perception, affect and behavior, which occur as a result of brain damage. Recognizing and treating these conditions is necessary not only for psychiatrists but for all physicians. Disorder of mental function is one of the most common associated conditions in intensive care unit (ICU) patients. However, disturbances of mental function often remain unrecognized. In ICU patients, different types of mental function disorders may develop. They range from sleep disorders, severe depression, anxiety, posttraumatic stress disorder (PTSD) to cognitive disorders including delirium. The causes of mental dysfunction in ICU patients can be divided into environmental and medical. Cognitive disorders are related to mental processes such as learning ability, memory, perception and problem solving. Cognitive disorders are usually not prominent in the early postoperative period and in many cases are discovered after hospital discharge because of difficulties in performing everyday activities at home or at work. The etiology of postoperative cognitive impairment is unclear. Older age, previous presence of cognitive dysfunction, severity of disease, and polypharmacy with more than four drugs are some of the risk factors identified. Delirium is a multifactorial disorder. It is an acute confusional state characterized by alteration of consciousness with reduced ability to focus, sustain, or shift attention. It is considered as the most common form of mental distress in ICU patients. Nearly 30% of all hospitalized patients pass through deliriant phase during their hospital stay. Delirium can last for several days to several weeks. Almost always it ends with complete withdrawal of psychopathological symptoms. Sometimes it can evolve into a chronic brain syndrome (dementia). The causes are often multifactorial and require a number of measures to ease the symptoms. Delirious patient is at risk of complications of immobility and confusion, leading to a high prevalence of irreversible functional decline. An interdisciplinary approach to delirium should also include family or other caregivers. In the diagnosis of delirium, several tests are used to complement clinical assessment. Among the most commonly used are the Confusion Assessment Method (CAM-ICU) and Clinical Dementia Rating (CDR) test. Depression is a common disorder among patients treated at ICU and occurs due to the impact of the disease on the body and the quality of life, independence, employment and other aspects of life. Depression can interfere with the speed of recovery, affects the postoperative quality of life, and in a certain number of patients may lead to suicidal thoughts and intentions. Phobias and generalized anxiety are the most common anxiety disorders. Generalized anxiety disorder is characterized by strong, excessive anxiety and worry about everyday life events. PTSD is delayed and/or protracted response to a stressful event or situation, extremely threatening or catastrophic nature, which is outside the common experience of people and would hit or traumatize almost all people. Treatment of delirium and other disorders is causal. The causes of psychosis are often multifactorial and require a number of measures to ease symptoms. The primary objective of prevention is appropriate therapy and correction of potential imbalances possibly underlying disturbances, stabilization of vital functions as well as early return to daily activities. Doctors and other medical staff must be aware of the importance and consequences of behavioral and emotional disorders in critically ill patients. Additional research is needed to discover the ways to prevent and/ or reduce the frequency and severity of the consequences and treatment of cognitive and emotional disorders.

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.