Enhanced recovery after cardiac surgery.

The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient's satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.

Emergency caesarean section delivery and puerperium in a patient with severe idiopathic pulmonary arterial hypertension - a case report.

BACKGROUND: The aim of this paper is to describe the third pregnancy trimester, delivery and puerperium in patient with idiopathic pulmonary hypertension. CASE REPORT: a 30-year-old primigravida with idiopathic pulmonary hypertension was qualified for emergency Caesarean section. In the post partum period no improvement in managing pulmonary arterial hypertension was achieved. Because of progressive respiratory and circulatory failure as well as the pulmonary artery pressure exceeding the systemic pressure the AV ECMO was applied on postoperative day 6. During the ECMO period the emergency laparotomy due to bleeding was necessary. The further course of ICU treatment was uneventful. CONCLUSION: In described case things are left to chance or goodwill of specialists and final outcome depend on happy coincidences.

Levosimendan in patients with low ejection fraction undergoing cardiac surgery.

INTRODUCTION: Significant impairment of left ventricular function causes low cardiac output syndrome in the immediate postoperative period in 3-14% of patients undergoing surgery, increasing the mortality 15-fold. AIM: To assess the use of levosimendan in patients undergoing cardiac surgery in 2016. MATERIAL AND METHODS: The analysis included 14 patients: 3 (21.4%) women and 11 (78.6%) men aged 65.4 ±11.8 years. The mean value of left ventricular ejection fraction amounted to 20 ±6.25%. In 11 patients, levosimendan infusion was started immediately after the induction of anesthesia. Three patients received the agent during the early postoperative period due to low cardiac output syndrome refractory to conventional therapy. The dosage was modified within the range of 0.05-0.2 µg/kg/min. On the day of the surgery, all patients received continuous infusion of adrenaline and levonor. RESULTS: The cardiac index amounted to 2.8 ±0.71 l/m2 after several hours of infusion and 2.9 ±0.1 l/m2 the next morning. The first examination showed that the mean systemic vascular resistance was 1010 dyn/s-5 and the second: 940 ±100 dyn/s-5; mixed venous blood saturation amounted to 66 ±7.5% and 65.5 ±8%, respectively. Respectively, the mean concentration of lactates was 2.0 ±0.96 mmol/l and 1.8 ±0.24 mmol/l. Mechanical lung ventilation lasting more than 48 hours was required in 50% of the patients. Two patients with chronic kidney disease required bedside renal replacement therapy before the procedure. Two (14.3%) patients died. Nine (64.3%) patients were discharged home, and three were transferred to cardiac wards. CONCLUSIONS: Levosimendan therapy proved safe in the study group. The nature of the study and the small sample size preclude the formulation of detailed conclusions.

Perioperative prognostic factors in patients with ruptured abdominal aortic aneurysms treated in the intensive care unit.

BACKGROUND: The incidence of abdominal aortic aneurysm has been estimated at 20-40 cases per 100,000 per annum. The disease is often asymptomatic; in many cases, its first symptom is shock caused by a ruptured aneurysm. The aim of the present study was to assess retrospectively the selected perioperative factors in patients hospitalised in the intensive care unit (ICU) after repair of ruptured abdominal aortic aneurysm. METHODS: Analysis involved medical records of patients after repair of ruptured abdominal aortic aneurysm treated in ICU in the years 2009-2010. Patients were divided into two groups: group I - survivors who were discharged from ICU and group II - non-survivors. Demographic factors, intraoperative data, vital parameters, laboratory results and severity of patient's state on admission to ICU were analysed. RESULTS: Analysis of laboratory results on admission to ICU showed lower values of pH and HCO(3)(-) concentrations as well as higher international normalised ratio (INR) and activated partial thromboplastin time (APTT) in group II. Mean intraoperative diuresis differed between the groups; in group I - 303 mL and in group II - 155 mL. Mean diuresis on ICU day 1 was higher in group I compared to group II, i.e. 20.87 and 11.27 mL kg b.w.-1, respectively. APACHE II, SAPS II, MODS and SOFA point values were higher in group I than in group II. CONCLUSIONS: Markers of impaired homeostasis, such as pH, HCO(3)(-) concentration, INR and APTT assessed on admission to ICU can be relevant prognostic factors in patients after repair of ruptured abdominal aortic aneurysm. Monitoring of diuresis during surgery and on day 1 of ICU treatment was a sensitive risk marker for acute kidney injury. Multiple organ failure scales such as APACHE II, MODS, SOFA and SAPS II were reliable prognostic tools to be used in the early period of ICU treatment.