Deskriptori TRANSPLANTACIJA JETRE; KRVARENJE; KRVNI DERIVATI; TROMBELASTOMETRIJA SAŽETAK. Uvod: Transplantacija ili presađivanje jetre jest priznata metoda liječenja kojom se terminalno bolesna jetra zamjenjuje sa zdravom jetrom darivatelja. Standardni laboratorijski testovi (protrombinsko vrijeme, aktivirano parcijalno tromboplastinsko vrijeme, fibrinogen, antitrombin), premda koreliraju s težinom jetrene bolesti, pokazali su inferiornost u odnosu na viskolelastične testove (trombelastogram – TEG i rotacijska trombelastometrija – ROTEM) u procjeni funkcije koagulacijskog sustava u terminalnoj fazi jetrene bolesti. Cilj ovog istraživanja bio je utvrditi na koji je način intraoperacijska upotreba viskolestičnih testova u procjeni hemostaze tijekom transplantacije jetre utjecala na transfuzijsko liječenje u Kliničkoj bolnici Merkur. Metode: Ovom retrospektivnom, opservacijskom studijom analizirane su slijedeće varijable za 76 pacijenta iz 2010. (bez ROTEM-a) te 82 pacijenta iz 2021. (s ROTEM-om) kojima je u KB Merkuru transplantirana jetra : intraoperacijska nadoknada tekućinama (kristaloidne, koloidne otopine); transfuzijsko liječenje krvnim derivatima (deplazmatizirani koncentrati eritrocita, svježe smrznuta plazma, trombociti, krioprecipitat); ukupni intraoperacijski gubitci (krv, diureza, međustanični prostor); ukupna nadoknada tekućinama i krvnim derivatima. Rezultati: Tijekom 2010. prosječna ukupna nadoknada tekućinama i krvnim derivatima bila je 18 433 ml dok je za 2021. bila 9838 ml (p<0,0001). Prosječni volumen kristaloidnih otopina ordiniranih 2010. tijekom transplantacije jetre bio je 5674 ml dok je 2021. bio 4734 ml (p=0,0015); koloidnih 2010. godine 2244 ml, a koloidnih 2021. godine 1949 ml (p=0,07). Prosječna količina deplazmatiziranih eritrocita ordinirana 2010. bila je 2927 ml dok je 2021. bila 1266 ml (p<0,0001). Prosječna količina svježe smrznute plazme, trombocita i krioprecipitata ordiniranih 2010. bila je 5428, 426, 266 ml dok je 2021. bila 823 (p<0,0001), 137 (p<0,0001), 366 ml (p<0,03). Zaključak: Uporabom viskoelastičnih testova za praćenje hemostaze tijekom transplantacije jetre značajno je smanjeno davanje svih krvnih derivata, osim krioprecipitata čija potrošnja je povećana, a nije utjecala na količinu ordiniranih koloidnih otopina. Smanjenje količine krvnih derivata je od iznimnog značaja s obzirom na rizike koje nosi transfuzijsko liječenje.

Aim: Although kidney transplantation is the best method of replacing renal function, there is still a need to improve long-term outcomes. The aim of this study was to determine the independent association of recipient and donor demographic factors, underlying renal disease, duration of dialysis treatment, tissue typing mismatch, and sensitization with transplant outcomes in a contemporary cohort of kidney transplant patients. Patients and methods: The study included patients who had a kidney transplantation at Clinical Hospital Merkur from June 2007 to the end of 2018. Transplant outcomes were monitored until December 31, 2019. The minimum follow-up time was 1 year. Data were collected using reports from the Eurotransplant Network Information System (ENIS) application (www.eurotransplant.org). Survival is shown by Kaplan-Meier curves. The association of survival with specific recipient and donor characteristics was analyzed by univariate and multivariate Cox regression. Results: In the period from June 2007 to the end of 2018, 480 kidneys were transplanted in 472 patients. The 10-year patient survival was 72%. Ten-year renal survival censored for the death of renal function patients was 93%. In the multivariate analysis, only recipient age at transplantation, diabetes as the cause of underlying renal disease and duration of dialysis remained independently associated with patient survival. Conclusion: Long-term graft survival is excellent after kidney transplantation. Long-term patient survival can be improved by prevention, early detection and intensive treatment of chronic diseases.

svježe smrznuta plazma 2244 ± 1523 i 5429 ± 1954, P < 0,001; trombociti 349 ± 387 i 426 ± 313, P = 0,176.Zaključci: Ovom studijom uočeno je značajno smanjenje ukupnog volumnog unosa, unosa koloidnih otopina, koncentrata eritrocita i svježe smrznute plazme tijekom transplantacije jetre u razdoblju od pet godina.Razlozi navedenog su ograničavanje perioperacijske volumne nadoknade u svrhu smanjivanja nepovoljnih učinaka volumnog preopterećenja.Ipak, najvažniji

Knjiga je Zbornik radova. Poglavlja: Anestezija s obzirom na stanje bolesnika ; Anestezija s obzirom na vrstu kirurskog zahvata ; Disni put ; Ostale domene

Velike epidemiološke studije upućuju na veliku učestalost sepse u općoj populaciji (1,2). Usprkos napretku kirurgije, kirurški pacijenti sa sepsom čine gotovo trećinu svih slučajeva sepse u SAD (3). Prema mišljenju nekih autora sepsa u kirurških pacijenata razlikuje se od one u ne-kirurških zbog modulacije imunološke funkcije koja se javlja kao posljedica kirurškog zahvata i primijenjene anestezije te bi stoga te dvije skupine trebalo pratiti odvojeno (4).

Objectives Chronic transplant dysfunction after kidney transplantation is a major reason of kidney graft loss and is caused by immunological and non-immunological factors. There is evidence that mycophenolate mofetil (MMF) may exert a positive effect on renal damage in addition to immunosuppression, by its direct antifibrotic properties. The aim of our study was to retrospectively investigate the role of MMF doses on progression of chronic allograft dysfunction and fibrosis and tubular atrophy (IF/TA). Setting Retrospective, cohort study. Participants Patients with kidney transplant in a tertiary care institution. This is a retrospective cohort study that included 79 patients with kidney and kidney–pancreas transplantation. Immunosuppression consisted of anti-interleukin 2 antibody induction, MMF, a calcineurin inhibitor±steroids. Primary outcome measures An association of average MMF doses over 1 year post-transplant with progression of interstitial fibrosis (Δci), tubular atrophy (Δct) and estimated-creatinine clearance (eCrcl) at 1 year post-transplant was evaluated using univariate and multivariate analyses. Results A higher average MMF dose was significantly independently associated with better eCrcl at 1 year post-transplant (b=0.21±0.1, p=0.04). In multiple regression analysis lower Δci (b=−0.2±0.09, p=0.05) and Δct (b=−0.29±0.1, p=0.02) were independently associated with a greater average MMF dose. There was no correlation between average MMF doses and incidence of acute rejection (p=0.68). Conclusions A higher average MMF dose over 1 year is associated with better renal function and slower progression of IF/TA, at least partly independent of its immunosuppressive effects.

Aim of this study was to evaluate level of analgesia and hemodynamic response to spinal anesthesia obtained by administering 15 mg 0.5% isobaric bupivacaine at L2-3 vs. L3-4 interspace for inguinal herniorrhaphy, since studies comparing analgesia and hemodynamic response at the L2-3 vs. L3-4 interspaces are lacking. In a prospective, randomized clinical study that encountered 72 patients undergoing elective inguinal herniorrhaphy randomly allocated in to two equal groups L2-3 (N = 36) and L3-4 (N = 36) according to lumbar interspace where intrathecal injection of bupivacaine was administered. Analgesia was evaluated by intraoperative "rescue" fentanyl requirements, the absence of pain and the maximal visual analogue scale (VAS) scores reached per patient during the operation. The severity of intraoperative pain was quantified by a 10 cm VAS scale (VAS 0: no pain to 10: worst pain imaginable) every 5 minutes after skin incision until the end of the operation. VAS > 3 was treated with intravenous fentanyl 25 microg. Hemodynamic response was monitored and evaluated, heart rate was continuously monitored as well as, baseline systolic, diastolic and mean arterial pressure prior to induction and every 5 minute after applying spinal anesthesia until surgical completion. Intraoperative fentanyl requirements were significantly higher in group L3-4 (L2-3 0%, 97.5% confidence interval [CI] 0.0-0.11 vs. L3-4 17%, 95% CI 0.07-0.32, p = 0.025). Absence of pain was significantly higher in L2-3 group at the beginning of the operation (L2-3 89%, 95% CI 0.74-0.96 vs. L3-4 67%, 95% CI 0.50-0.79, p = 0.047). The maximal VAS scores reached per patient during the operation in L2-3 group were lower then in L3-4 group (L2-3 median [M] 0, range [R] 0-3, L3-4 M 0, R 0-8, p = 0.014). There were no significant differences (p > 0.05) in the incidence of hypotension (L2-3 19%, 95% CI 0.09-0.35 vs. L3-4 17%, 95% CI 0.07-0.32) and bradycardia (L2-3 19%, 95% CI 0.09-0.35 vs. L3-4 8%, 95% CI 0.02-0.23). Spinal anesthesia with isobaric bupivacaine administered in L2-3 interspace for inguinal herniorrhaphy provides superior analgesia and equal hemodynamic stability as compared to neuroaxial anesthesia administered in the L3-4 interspace.

Aim To perform an external validation of the original Simplified Acute Physiology Score II (SAPS II) system and to assess its performance in a selected group of patients in major Croatian hospitals.Methods A prospective, multicenter study was conducted in five university hospitals and one general hospital during a six-month period between November 1, 2007 and May 1, 2008. Standardized hospital mortality ratio (SMR) was calculated from the mean predicted mortality of all the 2756 patients and the actual mortality for the same group of patients. The validation of SAPS II was made using the area under receiver operating characteristic curve (AUC), 2 x 2 classification tables, and Hosmer-Lemeshow tests.Results The predicted mortality was as low as 14.6% due to a small proportion of medical patients and the SMR being 0.89 (95% confidence interval [CI], 0.78-0.98). The SAPS II system demonstrated a good discriminatory power as measured by the AUC (0.85; standard error [SE]=0.012; 95% CI = 0.840-0.866; P<0.001). This system significantly overestimated the actual mortality (Hosmer-Lemeshow goodness-of-fit H statistic: X-2=5844; P<0.001 and C statistics: X-8(2)=313.0; P<0.001) in the group of patients included in the study.Conclusion The SAPS II had a good discrimination, but it significantly overestimated the observed mortality in comparison with the predicted mortality in this group of patients in Croatia. Therefore, caution is required when an evaluation is performed at the individual level.

The aim of this retrospective study was to evaluate and compare the incidence, timing and etiology of bloodstream infections (BSIs) in patients treated with liver-(LT) or hematopoietic stem cell transplantation (HSCT) in a single institution. We evaluated 280 consecutive transplantations over a period of 34 months. Our results demonstrated 84 episodes of BSIs (47 in LT patients and 37 in HSCT patients) at a median of 28 days post-transplantation. Relative incidence of 34.6 and 29.4 BSI episodes per 100 LT and HSCT patients, respectively, did not differ significantly between the two groups (p = 0.52). BSIs in HSCT patients occurred significantly earlier (p = 0.003) than in LT patients. The recently described reemergence of gram-negative (GN) pathogens as causative agents of BSIs in these patients was confirmed: GN bacilli were the predominant isolates in the LT group, responsible for 58.5% of BSIs and a very frequent (39%) cause of BSIs in the HSCT group. A higher incidence of resistant enterobacteriaceae producing extended spectrum beta-lactamases was found in isolates from LT patients compared to HSCT patients. In both groups, Pseudomonas aeruginosa was the most difficult to treat organism, with 57% of these isolates in LT patients and 44% in HSCT patients being resistant to carbapenems. To conclude, BSIs were confirmed to be important infectious complications of both LT and HSCT. Surveillance and analysis of bacteria causing bloodstream and other serious infections in transplanted patients remain the main prerequisites for planning interventions regarding prevention and treatment of infections in these patients.