Physical morbidity represents the deterioration of the general physical condition and it occurs as a result of illness and/or injury. When this condition is combined with acute diseases and limited mobility it is followed by a large number of complications that usually occur in patients treated in Intensive Care Units (ICU). Its treatment demands a comprehensive approach and early rehabilitation of the critically ill patients aimed at achieving the highest possible level of functionality within the boundaries of what is permitted by the illness/injury and its treatment. However, the prolonged period of immobilization of the critically ill is followed by shorter and/or longer periods of sequelae during and after treatment. The most common sequelae include physical deficits or psycho-emotional problems associated with PICS (post intensive care syndrome). General recommendations for early rehabilitation in the ICU undoubtedly point to the need of introducing physical therapy interventions as soon as possible, that is, as soon as the patient?s medical condition permits it. The primary goal of early rehabilitation of the critically ill during their stay in the ICU is to maximize the restoration of physical, psycho-emotional and social functions by implementing a personalized approach that reflects the needs of the patient.
Esophageal resection with reconstruction is complex surgical procedure with high rate of postoperative morbidity, with decreasing mortality rate during last decades, particularly in high-volume hospitals. Numerous preoperative, intraoperative and postoperative factors have contribute to incidence and type of complications. Intraoperative haemorrhage and tracheobronchial lesions could be avoid by good surgical judgement and operative technique. Pulmonary complications are often, with multifactorial etiology, and they are the main cause of postoperative mortality after esophagectomy. Dehiscence of esophageal anastomosis could be fatal, and only high index of suspicion and early diagnosis lead to successful treatment. In majority of such cases conservative measures are successful, however, conduit necrosis is indication for surgical reoperation. Vocal cord palsy due to intraoperative injury of recurrent laryngeal nerves is not rare and increases pulmonary complications rate. New onset of arrhythmia could be associate with other surgical complications. Postesophagectomy chylothorax is life-threatening complication due to rapid development of immunosuppression and septic complications, and early ligation of thoracic duct is often mandatory. Intrathoracic herniation of intrabdominal viscera is rare, and ischemic spinal cord lesions are very rare after esophagectomy. Majority of perioperative complications could be prevented or solved, decreasing mortality rate of esophagectomy.
Evolution of intensive care medicine in the last few decades and integrating teamwork has a major impact on increasing the rate of survival of patients. All the attention of the responsible team is not only aimed at treating the underlying disease, but also to decrease complications associated with prolonged stay in the ICU. The most common complications are: deconditioning, muscle weakness, polyneuropathy, myopathy, thromboembolic complications, decubital wound, artculation stiffness, cognitive disorders, depression, anxiety and a global reduction in quality of life. Physical therapy has its place in the earliest stages of treatment of mechanically ventilated patients. The aim of this article is to review the evidence for the use of rehabilitation in ICU in the adult mechanically ventilated patients. Early and systematically structured rehabilitation programs have been shown to be both safe and feasible for critical care populations.
Central venous pressure is a very common clinical measurement, but it is frequently misunderstood and misused. As with all hemodynamic measurements, it is important to understand its basic principles. Use of CVP for the estimating of cardiac preload and volume status requires an understanding of its determinants. Actually, CVP and cardiac output are determined by the interaction of two function curves: the cardiac function curve and the return curve. There are no data to support the widespread practice of using central venous pressure (CVP) to guide fluid therapy. But, CVP is readily available in many patients. The fact that an isolated measurement of CVP does not predict the response to a fluid bolus does not reduce its importance as a hemodynamic variable. CVP may be usefull taken in the context of the whole clinical picture and over time.
Introduction. Subarachnoid haemorrhage (SAH) can be followed by cardiac abnormalities. We describe a patient with Takotsubo cardiomyopathy and neurogenic pulmonary edema (NPE) after aneurysmal SAH. Case report. A previously healthy, postmenopausal woman, suffered from aneurysmal SAH with consequent hydrocephalus. After external ventricular drainage, craniotomy and clipping of the posterior inferior cerebellar artery aneurysm, the patient developed acute heart failure and NPE. Transthoracic echocardiogram showed the left ventricular apical ballooning and hypercontractile basal segments. On chest radiography, bilateral pulmonary infiltrates were seen. Seventeen days after the SAH attack, the patient was discharged from hospital. Postponed coronary angiography revealed no signs of coronary artery disease. Conclusion. This case and review of the relevant literature suggest that Takotsubo cardiomyopathy and neurogenic pulmonary edema are not uncommon after aneurysmal SAH.
Severe sepsis is the leading cause of mortality among children aged under the age of 5 years. The four main causes of sepsis in children are pneumonia, malaria, measles and diarrhoea. Preventing sepsis is extremely important and immunization of children and regular hand hygiene proved to be very efficient and cost effective in avoiding the development of diseases that may lead to sepsis. Clinical symptoms of all stadiums of sepsis in children are often non specific, but early diagnosis is extremely important. The initial treatment of sepsis in children has to be adjusted to the developmental stadium, age, the capacity of its immune system and the likely cause of infection. In studies on children early administration of antimicrobial therapy proved to be efficient. Early management of septic shock should consist of rapid boluses of crystalloids and 5% albumin solutions and administration of vasoactive medications until hemodynamic stability is achieved.
Traumatic pancreatitis is still a relative enigma, despite modern clinical practice, technology and modern diagnostic procedures. This condition is very specific and serious and is associated with significant morbidity, especially in pediatric population. Traumatic pancreatitis is also an emerging problem in pediatric population with its incidence rising in the last 20 years. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis due to trauma. Prospective multicenter studies are necessary to guide care and improve outcomes for this population.
Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. The treatment of burned children differs substantially from that of adults not only because of the different body proportions but also because of the metabolic processes involved, hormonal responses, the immunological profile, the degree of psychological maturation and healing potential. After assessing the overall physiological status of the child, accurate assessment of the burn injury and appropriate fluid resuscitation are of great importance. The severity of burn injury is characterized by the depth of the burn, total body surface area (TBSA) that is involved, the location of burn injury and the presence or absence of inhalation injury. Early excision and grafting, adequate nutrition, alleviation of the hypermetabolic response, treatment of hyperglycaemia, and physical therapy improve survival and outcomes in children with severe burns.
Despite the improvement of the understanding of the pathophysiology and treatment, in recent years, sepsis is the leading cause of death in children worldwide. Antibiotic therapy and hemodynamic support are the basis of treatment given to patients who survive circulatory failure and organ dysfunction. However, these patients may still suffer from many complications such as pulmonary embolism or stress ulcer. Although there is no clear evidence to quantify the importance of such complications on outcome, the anticipated impact is huge, having in mind the exhausted physiologic reserves of critically ill patients. Therefore, the critical patients who are being treated for severe sepsis in intensive care units, in addition to basic therapy, often also receive diverse forms of supportive therapy. This review summarizes the current evidence regarding the application of supportive therapy, which is included in international and domestic guidelines for the diagnosis, prevention and treatment of sepsis, severe sepsis and septic shock.
The goals of analgesia and sedation at the intensive care unit (ICU) are to facilitate mechanical ventilation, prevent patient and caregiver injury, and avoid the psychological and physiologic consequences of inadequate treatment of pain, anxiety, agitation, and delirium. Most ICU patients, especially the surgical and trauma ones, routinely experience pain at rest and with routine procedures. Treating pain in ICU patients depends on a clinician?s ability to perform a reproducible pain assessment and to monitor patients over time to determine the adequacy of therapeutic interventions to treat pain. Implementation of behavioral pain scales improves ICU pain management and clinical outcomes, including better use of analgesic and sedative agents and shorter durations of mechanical ventilation and ICU stay. Opioids are the primary medications for managing pain in critically ill patients. Multimodal approach to pain management in ICU patients has been recommended. Sedatives are commonly administered to ICU patients to treat agitation and its negative consequences. Sedation strategies using nonbenzodiazepine sedatives (propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients. It is recommend daily sedation interruption or a light target level of sedation be routinely used in adult intensive care patients using mechanical ventilation. Delirium affecting up to 80% of mechanically ventilated adult ICU patients. ICU protocols that combine routine pain and sedation assessments, with pain management and sedation-minimizing strategies, along with delirium monitoring and prevention, may be the best strategy for avoiding the complications of oversedation. Protocolized pain, agitation and delirium assessment (PAD ICU), is significantly associated with a reduction in the use of analgesic medications, ICU length of stay, and duration of mechanical ventilation.
Therapeutic hypothermia in selected patients surviving sudden out-of-hospital cardiac arrest can significantly improve rates of long-term survival and is considered as one of the most important clinical advancements in the science of resuscitation. Since 2003 the American Heart Association/International Liaison Committee on Resuscitation guidelines endorsed the use of hypothermic therapies as standard care for patients suffering from cardiac arrest while in 2005 additional inclusion and exclusion criteria were applied to patients experiencing in or out-of-hospital cardiac arrest with an initial shockable and non shockable rhythm. The goals of treatment in 2015 include achieving targeted temperature as quickly as possible with immediate initiation of cooling methods accompanied with supportive therapy and controlled rewarming.
Therapeutic hypothermia in selected patients surviving sudden out-of-hospital cardiac arrest can significantly improve rates of long-term survival and is considered as one of the most important clinical advancements in the science of resuscitation. Since 2003 the American Heart Association/International Liaison Committee on Resuscitation guidelines endorsed the use of hypothermic therapies as standard care for patients suffering from cardiac arrest while in 2005 additional inclusion and exclusion criteria were applied to patients experiencing in or out-of-hospital cardiac arrest with an initial shockable and non shockable rhythm. The goals of treatment in 2015 include achieving targeted temperature as quickly as possible with immediate initiation of cooling methods accompanied with supportive therapy and controlled rewarming.
Organ quality depends on variety of factors, including donor characteristics, effects of brain death, donor maintanance, the type of organ perfusion, cold ishaemia time and surgical procedures during organ recovery. Brain death influences on donor hemodynamics, hormone disregulation and consecutive inflammation of donor organs, which leads to organ dysfunction after transplantation. Due to disparity between organ demand and supply, an improvement in the use of allografts from deceased donors that are older, with significant comorbidity, has been observed recently. Assessment regarding deceased donor organ quality is based on donor demographic and clinical characteristics that are related to early and late outcome after transplantation. The transplant coordinator has a role in donor identification and selection, obtaining family consent for organ donation and communication with multidisciplinary teams during organ recovery organisation, which leads to an increased number of available organs and also their quality.
Preoperative neoadjuvant chemoradiotherapy (nCRT) followed by radical surgical resection is the mainstay of curative therapy in the management of patients with locally advanced (stage II and III) rectal carcinoma in order to reduce local recurrence and improve survival following surgery for rectal cancer. A brief survey of histopathological tumor regression grading (TRG) systems, other histomorphological and immunohistochemical findings and their clinical implications were reported including authors? experience. Possible diagnostic pitfalls are discussed specially on complete tumour regression (pCR), differentiation downstaging and downsizing and other aspects of standard histopathological examination and RT-induced histologic changes, including morphological, immunohistochemical and molecular transdifferentiation of tumour cells. Some of these histopathological parameters have to be considered when auditing rectal cancer resections and identifying prognostic factors
Despite the great progress that has been made in recent decades in the intensive treatment of critically ill patients with intra abdominal infections, antibiotic therapy and modern surgical techniques, secondary peritonitis is still accompanied by significant morbidity and mortality. The response to infection can be variable between different individuals. Scientific evidence support hypothesis that this inter-patient variability can be at least partially explained by genetic influence which may have an important role in the development of sepsis, as well as in severity of complications and death. An infection triggers complex immune response of the host and affects the balance between coagulation and fibrinolysis. This imbalance can lead to hypercoagulability but also to the microcirculation disturbance which can lead to multiple organ dysfunction syndrome (MODS) and septic shock. Common polymorphisms of genes which encode proteins with important role in coagulation and fibrinolysis could be of great importance in susceptibility for sepsis, possible complications and clinical outcome. Early genetic information may become very useful for identification of patients with high risk of developing severe sepsis and multiple organ dysfunctions, in order to design better, more personalized therapy with less severe adverse effects.
Background: Critically ill patients are the patients with life-threatening multiorgan disorders. In most cases the occurrence of life-threatening situation preceding the deterioration of basic vital parameters, which are often overlooked in outhospital and hospital conditions. For these reasons, the systematic monitoring of vital parameters is of great significance, and in that aim, the introduction in to the daily work, primarily in the hospital setting, the scoring system for the early identification of critically ill patients. There are several of these scoring systems, some of which are commonly used early warning scoring systems, which are measuring the vital parameters such as heart rate, blood pressure, respiratory frequency, temperature, oxygen saturation of peripheral blood and/or urine output, mental status changes. Numerous studies demonstrated the importance of the implementation of these systems in everyday clinical practice for the timely recognition of critically ill patients in the hospital setting in order to reduce mortality. According to some studies, these scoring systems have prognostic significance.
Background: Proctalgia fugax is a benign, self-limiting disease characterized by episodes of intense anorectal pain at frequent intervals in the absence of organic proctological disease.The aim of this study was to investigate patients of this condition and to treat them with sequential therapy. Material and Method: Author examined 46 patients with acute perianal pain-duration less than 30 minutes-without organic disease or previous perianal surgery since 2006 to 2015 in his Department. Author tretaed these patients using a three-step treatment: first step: hip bath, and benzodiazepines, second step: anal dilation, third step: internal lateral sphincterotomy if hypertrophy of the internal anal sphincter was demonstrated by endoanal ultra-sonography (EUS) and no improvement was confirmed with the previous steps of treatment. Results: 46 patients with an average follow-up of 6 years. EUS confirmed a grossly thickened internal anal sphincter in 12 cases. After the first step of our sequential treatment 23 patients improved and 2 patients cured, after the second step of treatment 12 patients had remarcable improvement and 3 patients cured and after the third step of treatment 8 patients had remarcable improvement and 3 patients cured. Conclusion: A total resolution of Proctalgia fugax is not possible, but we may improve symptoms and their frequency. EUS can help in the diagnosis of organic diseases or internal anal sphincter hypertrophy, for which we can perform an internal anal sphnicterotomy.
The mortality rate from ST elevation myocardial infarction (STEMI) varies in European countries, from 6 to 14%. Timely established diagnosis and urgent reperfusion therapy, primarily by primary percutanous intervention with stent implantation (pPCI) in an infarct related artery is essential for mortality reduction and prevention of complications. European Society of Cardiology has made recommendations for preferred and acceptable time frames for diagnosis and therapy of STEMI. The preferred time for diagnosis of STEMI from the first medical contact (FMC) is = 10 min. From the FMC to balloon inflation in the infarct related artery (reperfusion) maximal accepted time is 120 min. If that time frame cannot be reached, fibinolysis is indicated. In order to ameliorate the treatment of these patients, STEMI network has been established in the European countries, including Serbia. Serbia has 12 primary PCI hospitals and, in spite of numerous obstacles, more than 4000 pPCI procedures have been performed during 2015.
Purpose: Internal rectal prolapse frequently occurs in older, sometimes polymorbid patients. Trans-abdominal operation is therefore not always in the patient?s best interest. The aim of this retrospective study was to demonstrate that the Delorme?s procedure is feasible and safe to be performed in an outpatient setting. Methods: This study is a retrospective review of a single-institution experience. Fifty-one patients (age 64.7 ? 12.5, range 35 to 90 years) with internal rectal prolapse were treated with Delorme?s procedure during 6-year period. Patients were assessed at follow-up 1 and 6 weeks after the surgery and phone interview was performed after 51.4 ? 16.5 months after operation. Results: All 51 patients were operated under spinal anesthesia and observed for approximately 6 hours before discharge. Six patients needed referral to inpatient hospital for safety observation after the procedure. There were no mortalities in our study. One patient developed anaerobic infection and needed a colostomy. Out of 34 presenting with sensation of incomplete evacuation, 28 (82.4%) reported improvement after procedure, 13 out of 15 (86.7%) reported improvement in obstructed defecation symptoms and 4 out of 7 patients (57.1%) reported improvement in incontinence. Average sick leave was 16.0 ? 4.3 days. Seven patients suffered from postoperative stenosis. Recurrence was seen in 5 cases (9.8%). Majority of the patients (73,3%) would recommend this procedure for problems similar to their own. Conclusion: Our study shows that the Delorme?s procedure is feasible in an outpatient setting, with reasonable complications and satisfactory outcome.
Background: Although there is no consensus concerning the definition of the ?hostile? pelvis, variant colo-anal pull-through procedures may be used for salvage surgery. This paper reports a single surgeon experience of these operations providing technical caveats for their use. Methods: Retrospective single surgeon analysis of cases between 1993 and 2015 Results: The main techniques included Soave and Duhamel reconstructions for an eclectic range of colorectal conditions including post-obstetric rectovaginal fistulae, the management of anastomotic leakage after low anterior resection and neoadjuvant chemoradiation, rectoprostatic fistulae, extralevator anorectal fistulae and intractable Crohn?s proctitis. The complication rate was 31.8% with 86.4% avoiding a permanent stoma. Fifty percent of patients reported normal continence during a median follow-up of 29 months. Conclusion: Modifications of the colo-anal pull-through procedure are successful as salvage for a range of chronic colorectal conditions. A randomized trial is required to determine the place for a staged delayed anastomosis.
