44 research outputs found
The impact of isolated bacteria resistance on treatment outcome in patients with Gram negative sepsis at the Intensive Care Unit at University Hospital Centre Zagreb
No full textSepsa je upalni odgovor organizma na prisutnost bakterija i njihovih toksina u organizmu. Liječenje sepse temelji se na eradikaciji uzročnika, održavanju hemodinamike i liječenju organske disfunkcije. Mnogi uzročnici sepse razvili su rezistenciju na antibiotike te empirijska terapija ponekad nije učinkovita, što može rezultirati nepovoljnim ishodom. Istraživanje je temeljeno na retrospektivnoj studiji populacije bolesnika liječenih u Zavodu za intenzivnu medicinu Kliničkog bolničkog centra Zagreb u trogodišnjom razdoblju od 01.01.2013. do 31.12.2015. tijekom kojeg su zabilježene 1962 hospitalizacije. Podaci o broju bolesnika, izolatima te antibiogramima prikupljeni su iz aplikacije bis (bolnički informacijski sustav) te bili upisivani u tabličnom obliku, a nakon toga statistički obrađeni u programu Statistical Package for the Social Sciences (SPSS). Iz pozitivnih hemokultura bilježena je osjetljivost izoliranih Gram negativnih uzročnika i promatran je ishod bolesnika. Udio bolesnika hospitaliziranih u Zavodu s dokazanom Gram negativnom sepsom konstantan je kroz trogodišnje razdoblje i kreće se oko 7%. Pseudomonas aeruginosa je najčešći izolat u bolesnika s Gram negativnom sepsom s visokim udjelom rezistencije 29 od 53 izolata, odmah nakon Acinetobactera u kojeg je 25 od 27 izolata multirezistentno. Učestalost izolata P. aeruginosa u bolesnika s Gram negativnom sepsom raste kroz promatrano razdoblje od tri godine. Ishod je najnepovoljniji kod miješane Gram negativne sepse uzrokovane s dva ili više uzročnika, a od pojedinačnih uzročnika najnepovoljniji je kod infekcije uzrokovane nonfermentorima P. aeruginosa i A. baumannii u kojih je i udio rezistencije najveći. Bolesnici s Gram negativnom sepsom uzrokovanom multirezistentnim bakterijskim sojevima imaju značajno veću smrtnost od bolesnika čija je sepsa uzrokovana osjetljivom sojevima.Sepsis is a clinical syndrome that occurs as the result of invasion of bacteria and their toxins into the circulation which causes an inflamatory sistem response. The treatment of sepsis is based on the eradication of isolated microorganisms, maintance of haemodynamics and treatment of organ dysfunction. Most causes of sepsis developed a resistance to antibiotics. Therefore, empiric antibiotic therapy can be inefficient, which can result with an adverse outcome. A three – year retrospective study was conducted in patients hospitalized at the Intensive care unit in University Hospital Centre Zagreb from 1 January 2013 until 31 December 2015. During this period 1962 patients were observed. Data about numbers of patients, isolated microorganisms and results of antibiograms were collected from bis application (hospital system of informatization), written up in tables and statistically processed in the Statistical Package for the Social Sciences SPSS. Resistance of Gram negative microorganisms and outcome of patients were collected. The percentage of patients with Gram negative sepsis hospitalized in the Department was stable and around 7%. P. aeruginosa was the most common isolate, with a high percentage of multiresistance (29/35 isolates), right after A. baumannii (25/27). The incidence of P. aeruginosa isolatesbacteria on the increase. The outcome was the worst in mixed Gram negative sepsis caused with 2 or more microorganisms, while among individual bacterial species the outcome was the worst in infections caused by non fermenters P. aeruginosa and A. baumannii, which have the highest percentage of multiresistance. Patients with Gram negative sepsis caused by multiresistant bacterial strains had a significaly higher mortality than patients with sepsis caused by sensitive strains
Ultrasound in the diagnosis of pulmonary embolism
No full textVenska tromboembolija hitno je stanje koje, ako se rano ne prepozna, rezultira visokim mortalitetom. Plućna embolija treći je
najčešći uzrok smrti povezan s kardiovaskularnim bolestima. 90% embolusa potječe od tromba iz dubokog venskog sustava nogu. Zlatni standard za dijagnostiku plućne embolije trenutno je MSCT angiografija. Glavni nedostatci ove metode su zračenje i nefrotoksičnost kontrasta. Zlatni standard za slikovnu dijagnostiku DVT-a je CD UZV dubokih vena nogu. VTE kod hemodinamski stabilnih bolesnika liječimo antikoagulantnim lijekovima. Cilj istraživanja bio je pokazati u kojem je postotku bolesnika s MSCT angiografijom verificiranom PE moguće CD UZV-om dokazati prisutnost DVT-a. Ovo retrospektivno presječno istraživanje obuhvatilo je 114 bolesnika hospitaliziranih u Zavodu za intenzivnu medicinu Kliničkog bolničkog centra Zagreb i Medicinskog
fakulteta Sveučilišta u Zagrebu, kod kojih je MSCT angiografijom verificirana masivna ili submasivna PE. Svim bolesnicima je, uz MSCT angiografiju, učinjen i UZV pluća, te CD UZV dubokih vena nogu. Svim bolesnicima, koristeći podatke iz otpusnih pisama,
izračunali smo Wells score za PE i za DVT. Potom je učinjena deskriptivna statistika. Rezultati našeg istraživanja pokazali su da 66 od 114 bolesnika (57,9%) ima CD UZV-om dokaziv DVT. Obzirom da se za liječenje i DVT-a i PE koriste jednaki lijekovi u jednakim dozama, nameće se pitanje potrebitosti MSCT angiografije.Venous thromboembolism is an emergency condition that, if not recognized early, results in high mortality. Pulmonary embolism is the third most common cause of death associated with cardiovascular disease. 90% of emboli originate from a thrombus from the deep venous system of the legs. The gold standard for the diagnosis of pulmonary embolism is the MSCT angiography. The main disadvantages of this method are radiation and contrast nephrotoxicity. The gold standard for DVT imaging is CD ultrasound of the deep veins of the legs. VTE in hemodynamically stable patients is treated with anticoagulant drugs. The aim of the study was to show in what percentage of patients with MSCT angiography- verified PE is possible to prove the presence of DVT by CD ultrasound. This retrospective cross-sectional study included 114 patients hospitalized in the Department of Intensive Care Medicine of the Clinical Hospital Center Zagreb and the Medical Faculty of the University of Zagreb, in whom the massive or submassive PE was verified by MSCT angiography. In addition to MSCT angiography, all patients underwent lung ultrasound and CD ultrasound of the deep veins of the legs. For all patients, using data from discharge letters, we calculated the Wells score for PE and DVT. We performed the descriptive statistical analysis. The results of our study showed that 66 of 114 patients (57.9%) had CD ultrasound-detectable DVT. Since the same drugs in equal doses are administered to treat both DVT and PE, the question of the need for MSCT angiography in those patients arises
Lung ultrasound in diagnostics of acute respiratory conditions
No full textAkutna respiratorna stanja su stanja koja naglo nastaju i uzrokuju narušenje funkcije disanja, odnosno dispneju. Glavni dijagnostički izazov je odrediti etiologiju dispneje. Standardne metode uključuju klinički pregled, odnosno auskultaciju te radiološke metode, u prvom redu radiografiju pluća. Kompjuterizirana tomografija je najpreciznija metoda, međutim zbog brojnih razloga kao što su velike doze zračenja i nemogućnost primjene pretrage uz krevet bolesnika teško može postati metoda prvog izbora u akutnoj respiracijskoj insuficijenciji. Ultrazvuk pluća pokazao je veliku osjetljivost i specifičnost u diferencijalnoj dijagnozi najčešćih akutnih respiratornih stanja. Ova metoda primjenjiva je uz krevet bolesnika, može se koristiti i izvan bolnice, njome se lako prati razvoj bolesti te ne izlaže bolesnika ionizirajućem zračenju. Donedavno se mislilo da ultrazvuk pluća nema nikakvu kliničku važnost zbog gotovo potpunog odbijanja ultrazvučnih valova od površine pluća što onemogućuju pregled pluća ultrazvukom za razliku od pregleda solidnih organa. Međutim, Lichtenstein je otkrio da promatranjem pleure i njoj pridruženih artefakata može doći do ključnih informacija za postavljanje ispravne dijagnoze. Na temelju svojih otkrića razvio je dijagnostički algoritam „BLUE protocol“ koji se pokazao ispravnim u pronalaženju točnog uzroka akutne respiracijske insuficijencije u značajnom broju slučajeva. Ultrazvuk pluća u mnogim je istraživanjima pokazao bolju osjetljivost i specifičnost od radiografije pluća te je stoga moćna dijagnostička metoda u rukama iskusnog kliničara. Potrebna su daljnja istraživanja kako bi se u potpunosti iskoristili njezini potencijali.Acute respiratory conditions are conditions which cause sudden deterioration of respiratory function, also known as dyspnea. Main diagnostic challenge is to determine the etiology of dyspnea. Standard methods include clinical examination, most importantly auscultation and radiologic procedures. Most commonly used is chest radiography. Computerized tomography is a method of highest accuracy, however due to numerous reasons like high radiation dosage or incapability of performing the procedure bedside it can hardly become the method of choice in acute respiratory failure. Lung ultrasound has shown to be highly sensitive and specific in differential diagnosis of the most frequent acute respiratory conditions. This method can be applied bedside, it can be used even outside of hospitals, the follow-up is easy and it does not expose patients to ionizing radiation. It had been considered until recently that lung ultrasound is of no clinical importance due to almost complete reflection of ultrasound waves against lung surface, which makes lung ultrasound examination impossible. However, Lichtenstein revealed that by examining pleura and joined artefacts key information for making a right diagnosis can be obtained. Based on his discoveries, he developed a diagnostic algorithm „BLUE protocol“ which showed great accuracy in detecting the correct cause of acute respiratory insufficiency in a significant number of cases. Many studies show that lung ultrasound is more sensitive and more specific in comparison to chest radiography what makes him a powerful tool in hands of an experienced clinician. Further research needs to be undertaken in order to fully use its potential
Techniques and methods of teaching ultrasound examination of the inferior vena cava for the purpose of central venous pressure and volume status assessment
No full textU ovom istraživanju pokušali smo procijeniti broj pregleda ultrazvukom potrebnih da
student medicine nakon praktične i teorijske obuke dosegne zadovoljavajuću razinu u
procjenjivanju centralnog venskog tlaka (CVT) pregledom donje šuplje vene (DŠV)
ultrazvukom. Također smo provjerili je li neki od pristupa za dobivanje slike superiorniji nad
ostalima.
Promjer DŠV mjeren je u inspiriju i ekspiriju pristupom iz epigastrija i interkostalnim
pristupom. U oba pristupa DŠV je mjerena na poprečnom i uzdužnom prikazu. Svakog
bolesnika ultrazvukom su pregledali student i iskusni liječnik vičan ultrazvuku. Za svaki pristup
su procijenili CVT na temelju promatranja kolabiranja donje šuplje vene tijekom disanja te
proveli mjerenja promjera vene i na temelju njih procijenili tlak koristeći ASE tablicu. Niti
jedan ispitivač nije imao uvid u rezultate drugog ispitivača kao niti u vrijednost CVT-a
izmjerenog pomoću postavljenog centralnog venskog katetera.
U istraživanje je bilo uključeno 30 bolesnika. Nakon prvih 15 bolesnika podudaranje
između studenta i specijalista prema Cohenovom kapa koeficijentu se nalazilo u stupnju
blagoga podudaranja kako za slobodnu procjenu kategorije CVT-a tako i za mjerenja u B i M
modu ultrazvuka, a nakon pregledanih idućih 15 bolesnika podudaranje se poboljšalo do stupnja
umjerenog podudaranja oba ispitivača za slobodnu procjenu i za mjerenja u B i M modu.
Nakon 30 pregleda ultrazvukom student je poboljšao svoje sposobnosti procjene CVTa
na temelju pregleda DŠV ultrazvukom. Niti iskusni specijalist nije pokazao da može precizno
procijeniti CVT ovom metodom u populaciji intenzivističkih bolesnika u kojih osim volemije i
drugi čimbenici utječu na promjer DŠV. Stoga nije moguće sa sigurnošću procijeniti studentovu
osposobljenost za upotrebu ove metode nakon pregledanih 30 bolesnika. Slobodna procjena
pokazala se manje uspješnom za predikciju CVT-a nego metoda temeljena na mjerenjima.
Različite metode mjerenja, uz uzdužni ili poprečni prikaz DŠV, iz epigastrija ili interkostalnim
pristupom, te u B ili u M modu nisu pokazale značajnu međusobnu razliku.The aim of this study was to assess the number of ultrasound examinations needed for
the medical student to reach a reasonable level of proficiency in ultrasonic evaluation of central
venous pressure (CVP), and to check the value of different inferior vena cava (IVC) assessment
methods in CVP estimation.
The diameter of the IVC in the inspiration and the expiration was evaluated and
measured by the epigastric and the intercostal approach, showing the transverse and
longitudinal section in the B and M modes. Without insight into the value of CVP and the results
of other examiner, a student and a specialist experienced in ultrasonography examined each
patient. CVP was predicated by free evaluation and by the reading from the ASE table based
on the measurements. Neither examiner had insight into other examiners results nor had the
examiners insight into the CVP measured via the central venous catheter.
Thirty patients were included in the study. After the first 15 patients, the agreement
between the student’s and the specialist’s categorization of CVP according to the Cohen’s
kappa coefficient was in a slight degree for both the free evaluation of CVP and B and M mode.
After the examination of the next 15 patients, the agreement was in the fair degree for both the
free evaluation of CVP and B and M mode.
After 30 ultrasound examinations the student improved his capabilities of assessing
CVP based on ultrasonic evaluation of IVC. Experienced specialist, as well as student, wasn’t
efficient in accurate assessment of CVP by this method in the population of adult intensive care
unit patients that, besides volume status, had other factors that influence the diameter of IVC.
Therefore it is not possible to assess the student’s capabilities of using this method with
certainty after examining 30 patients. The free estimate was found to be less accurate in CVP
prediction than the measurement of the IVC diameter. With the respect to the CVP prediction,
no significant differences were found between the measurements in the longitudinal or
transverse plane as well as between examinations from the epigastrium or intercostal spaces.
This was found in both B and M mode
Uloga određivanja laktata u krvi u diferencijalnoj dijagnozi akutne boli u prsištu
No full textDouble blind prospective clinical study tested the usefulness of blood lactate levels for stratification of patients with chest pain in emergency department. 159 patients meet all inclusive criteria.
The highest average blood lactate concentration was found in the group of patients with acute myocardial infarction with ST segment elevation (3,19 mmol/L), what is significantly different from all other groups of patients. Statistical significance was found between blood lactate concentrations in patients with unstable pectoral angina (average blood lactate concentration of 2.12 mmol/L) and patients with acute myocardial infarction without ST segment elevation (average blood lactate concentration of 2,22 mmol/L), comparing with patients with noncoronary aetiology of chest pain (average blood lactate concentration 1,7 mmol/L).
By logistic regression the ability of blood lactate to predict acute myocardial infarction, when cut off point of 1,5 mmol/L is chosen, sensitivity is 94 %, negative predictive value is 92,3%, with specificity of 34,7%. The method is even more powerful for prediction of acute myocardial infarction with ST segment elevation where sensitivity is 97,3%, and negative predictive value is 97,4%. When blood lactate concentrations are less then 1,5 mmol/L, the probability of acute coronary syndrome is low. Sensitivity is 90,8% and negative predictive value is 82%. At cut off point level of 2,5 mmol/L specificity for prediction of acute myocardial infarction is 86,7%. At cut off point level of 3,5 mmol/L specificity is 100% as well as is the positive predictive value.
Similar predictive power for prediction of acute myocardial infarction exists even when patients arrive in the emergency department in the early phase of myocardial infarction, prior to troponin I rises.
There is a good correlation between blood lactate concentrations and infarct size.
It can be concluded that blood lactate measurements in patients with chest pain in emergency department could be helpful in the recognition of patients with acute coronary syndrome, even in the early phase, particularly in those with acute myocardial infarction with ST segment elevation
Severe Acute Pancreatitis as a Part of Multiple Dysfunction Syndrome
No full textAcute pancreatitis is a disease with various degrees of clinical manifestations. Mild and moderate severe acute pancreatitis is an illness characterized with chemical inflammation which, in general, passes without major complications. Clinical picture of severe acute pancreatitis other side is commonly complicated with functional deterioration of other organs, and frequently has characteristics of multiple organ dysfunction or failure syndrome with or without bacterial super infection. We studied 82 patients admitted to the intensive care unit with severe acute pancreatitis, 14 died. The mortality was in statistically significant correlation with the severity of clinical condition at admission assessed by APACHE II score, and higher Ranson’s and Glasgow criteria by admission. Adequate volume supplementation, on time, as well as percutaneous drainage of infected pancreas collection reduces a risk of pure outcome
Thrombotic Thrombocytopenic Purpura – The Role of ADAMTS13 Assay in Clinical Practice
No full textThrombotic thrombocytopenic purpura (TTP) is a disorder characterized by disseminated thrombotic occlusions of the microcirculation. Identification of ADAMTS13 protease and its place in the pathophysiology of TTP led to better understanding of the disease and better survival for the diseased. Here we show a case report of a patient that had a normal ADAMTS13 protease activity and an unusual clinical presentation and utilize that case to highlight how the absence of a severe ADAMTS13 protease deficiency does not preclude a diagnosis of TTP and how early initiation and continuation of plasma exchange therapy can lead to a positive outcome, even in a severely ill patient. Even though ADAMTS13 protease determination has no immediate influence on the decision whether or not to start the plasma exchange therapy, it has great impact on future management of the patient and should be determined whenever possible
Trombotak trombocitopenična purpura: uloga testa ADAMTS13 proteaze u kliničkoj praksi
No full textThrombotic thrombocytopenic purpura (TTP) is a disorder characterized by disseminated thrombotic occlusions of the microcirculation. Identification of ADAMTS13 protease and its place in the pathophysiology of TTP led to better understanding of the disease and better survival for the diseased. Here we show a case report of a patient that had a normal ADAMTS13protease activity and an unusual clinical presentation and utilize that case to highlight how the absence of a severe ADAMTS13 protease deficiency does not preclude a diagnosis of TTP and how early initiation and continuation of plasma exchange therapy can lead to a positive outcome, even in a severely ill patient. Even though ADAMTS13 protease determination has no immediate influence on the decision whether or not to start the plasma exchange therapy, it has great impact on future management of the patient and should be determined whenever possible.Trombotska trombocitopenična purpura (TTP) je bolest karakterizirana diseminiranim trombotskim okluzijama mikrocirkulacije. Identifikacija ADAMTS13 proteaze i njenog mjesta u patofiziologiji bolesti dovelo je do boljeg razumijevanja bolesti i boljeg preživljenja oboljelih. Ovaj rad je prikaz slučaja bolesnica s normalnom razinom ADAMTS13 aktivnosti i neobičnom kliničkom prezentacijom uz pomoć kojega želimo naglasiti kako odsustvo teškog pomanjkanja ADAMTS13 aktivnosti ne izuzima dijagnozu TTP i kako rano započinjanje i nastavak terapije izmjenom plazme može dovesti do pozitivnog ishoda, čak i u teško oboljelih. Iako određivanje nedostatka ADAMTS13 aktivnosti nema trenutni utjecaj na odluku da li ili ne započeti terapiju izmjenom plazme, ima veliki utjecaj na daljnje terapijske odluke i trebala bi biti pokušana kad god je to moguće
Trombotak trombocitopenična purpura: uloga testa ADAMTS13 proteaze u kliničkoj praksi
No full textThrombotic thrombocytopenic purpura (TTP) is a disorder characterized by disseminated thrombotic occlusions of the microcirculation. Identification of ADAMTS13 protease and its place in the pathophysiology of TTP led to better understanding of the disease and better survival for the diseased. Here we show a case report of a patient that had a normal ADAMTS13protease activity and an unusual clinical presentation and utilize that case to highlight how the absence of a severe ADAMTS13 protease deficiency does not preclude a diagnosis of TTP and how early initiation and continuation of plasma exchange therapy can lead to a positive outcome, even in a severely ill patient. Even though ADAMTS13 protease determination has no immediate influence on the decision whether or not to start the plasma exchange therapy, it has great impact on future management of the patient and should be determined whenever possible.Trombotska trombocitopenična purpura (TTP) je bolest karakterizirana diseminiranim trombotskim okluzijama mikrocirkulacije. Identifikacija ADAMTS13 proteaze i njenog mjesta u patofiziologiji bolesti dovelo je do boljeg razumijevanja bolesti i boljeg preživljenja oboljelih. Ovaj rad je prikaz slučaja bolesnica s normalnom razinom ADAMTS13 aktivnosti i neobičnom kliničkom prezentacijom uz pomoć kojega želimo naglasiti kako odsustvo teškog pomanjkanja ADAMTS13 aktivnosti ne izuzima dijagnozu TTP i kako rano započinjanje i nastavak terapije izmjenom plazme može dovesti do pozitivnog ishoda, čak i u teško oboljelih. Iako određivanje nedostatka ADAMTS13 aktivnosti nema trenutni utjecaj na odluku da li ili ne započeti terapiju izmjenom plazme, ima veliki utjecaj na daljnje terapijske odluke i trebala bi biti pokušana kad god je to moguće
