Idiopathic Capillary Leak Syndrome (ICLS), also known as Clarkson’s disease, is a rare yet potentially life-threatening disorder of unknown etiology. It is a clinical condition that is frequently overlooked, but represents a severe and potentially fatal illness, characterized by fluid extravasation into the interstitial space, resulting in hemoconcentration, generalized edema, effusions, and hypotension. Owing to the similarity of its symptoms to those of other conditions, ICLS is often underdiagnosed, thereby posing a challenge for patient management. We report a complex case of a 69-year-old patient who presented with shock secondary to a necrotic cecal tumor and was ultimately diagnosed with ICLS. This case underscores the diagnostic challenges, the need for awareness and need for precision monitoring in differentiating ICLS from other causes of shock and emphasizes the critical importance of early recognition and appropriate therapeutic intervention. Additionally, a review of the current understanding of ICLS pathophysiology, diagnostic criteria, and treatment strategies, based on existing evidence, is provided.

BACKGROUND:Hemoadsorption is considered currently as an adjunct therapy for the treatment of rhabdomyolysis and acute kidney injury (AKI) although the exact timing is not yet determined. We hypothesised that earlier start of hemoadsorption in patients with ischemia/reperfusion caused rhabdomyolysis and AKI leads to a better clinical improvement and recovery of kidney function. MATERIALS AND METHODS:We conducted a single-center, retrospective cohort study. Treatment was defined as the use of hemoadsorption with CytoSorb® in combination with continuous renal replacement therapy (CRRT) compared to patients who were treated only with CRRT. Patients were divided in early and late initiation of hemoadsorption subgroups by less or more than 12 hours after developing acute kidney injury. Myoglobin and creatine kinase plasma levels were measured shortly before, 12 hours after the start of treatment, and 24, 48, and 72 hours after initiation. The follow-up lasted until the last enrolled patient reached 60 days after first hemoadsorption procedure. RESULTS:Overall, 30 patients were included in the treatment arm and 25 patients in the control group. Significant decrease of myoglobin levels was observed in the hemoadsorption treated group in all time points when compared with the control group. Logistical regression analysis found the association of hemoadsorption use and shorter duration of AKI (OR 3.46) and less acute kidney disease (AKD) (OR 2.85). Earlier start of hemoadsorption was associated with a statistically significant shorter duration of AKI (OR 3.22) and less AKD (OR 3.10). Patients treated early with hemoadsorption survived significantly longer than patients treated late (49.2 vs 15.3 days; p < 0.001). CONCLUSIONS:Early start of combined CRRT and hemoadsorption therapy with CytoSorb was safe and associated with improved kidney recovery and survival in patients with ischemic/reperfusion rhabdomyolysis and AKI. Early start of hemoadsorption might prevent renal failure and acute kidney disease and shorten the CRRT dependency in patients who develop AKI.

Background: Early identification of liver transplant (LT) recipients at risk of graft failure is crucial to allow timely retransplantation. Lactate levels have been proposed as markers of graft dysfunction, although their optimal timing and predictive value remain uncertain. This study aimed to investigate the prognostic role of early postoperative lactate measurements for predicting 90-day graft loss after LT and compare their performance with established early allograft dysfunction scores. Methods: This retrospective observational study included adult patients undergoing their first LT at the Sapienza University of Rome (Italy) between 2013 and 2021, with external validation in an independent cohort from Zagreb University (Croatia) between 2022 and 2025. Lactate levels were evaluated at declamping, at the end of transplantation, and as the peak value within the first postoperative day. Their predictive ability for 90-day graft loss was compared with Early Allograft Dysfunction (EAD) and the Model for Early Allograft Function (MEAF) score using receiver operating characteristic (ROC) analysis. Results: A total of 268 LT recipients were analyzed (178 Sapienza and 90 Zagreb). Ninety-day graft loss occurred in 25 (14.0%) patients in Sapienza and 10 patients (11.1%) in Zagreb. A lactate peak within the first postoperative day showed the highest discriminative ability for predicting graft loss in both cohorts (Sapienza: AUC 0.87, 95%CI 0.77-0.98, p < 0.001; Zagreb: AUC 0.79, 95%CI 0.62-0.97, p = 0.003). This outperformed EAD and MEAF. A lactate peak cutoff of 5.0 mmol/L (75th percentile) resulted in 80.0% sensitivity and 86.3% specificity in Sapienza and 80.0% sensitivity and 68.7% specificity in Zagreb. Higher thresholds increased specificity, reaching 98.7% and 95.0% at 8.4 mmol/L in the Sapienza and Zagreb cohorts, respectively. Patients with a lactate peak ≥ 5.0 mmol/L showed significantly higher 90-day graft loss compared with those below the threshold in both cohorts (Sapienza: 47.6% vs. 4.7%, p < 0.001; Zagreb: 25.0% vs. 5.0%, p = 0.004). Conclusions: The peak lactate value during the first postoperative day represents a simple and accurate biomarker for predicting early graft loss after LT. Its superior predictive performance compared with commonly used EAD-related scores suggests that the lactate peak may represent a valuable tool for early postoperative risk stratification.

Background: Early graft loss after liver transplantation (LT) remains a major challenge. Most predictive models rely on isolated factors or post-transplant variables, limiting their utility in pre-transplant decision-making. We developed a novel score integrating donor, recipient, and procedural variables to estimate 12-month graft loss based on the balance between risk and mitigation factors. Methods: In this retrospective study, 268 adult primary LT recipients from two European centers were analyzed. The primary endpoint was 12-month graft loss (death or retransplantation). Independent predictors were identified using multivariable logistic regression based on pre-transplant variables. A population-centered approach quantified individual deviations from average risk, classifying variables as risk exposure or mitigation factors. These were combined into a Risk-Mitigation Balance score. Model performance was evaluated using AUC and Brier score, and patients were stratified into three risk groups. Results: Twelve-month graft loss occurred in 17.9% of patients. Acute liver failure and warm ischemia time were the strongest predictors. The Risk-Mitigation Balance score showed good discrimination (AUC = 0.74) and calibration (Brier score 0.116), outperforming early post-transplant models (AUC = 0.65). Stratification identified three groups with significantly different graft loss rates: 7.4% (mitigation), 14.8% (intermediate), and 44.2% (risk) (p < 0.001), with clear separation on survival analysis. Conclusions: This novel score enables pre-transplant estimation of graft loss by integrating risk and modifiable factors, supporting more informed and personalized allocation decisions.

Background:Needlestick and sharps injuries are common occupational hazards among health care workers and may result in exposure to bloodborne pathogens. Aim:To assess reported needlestick and sharps injuries among health care workers at 2 university hospitals in Croatia. Methods:We collated and analysed national surveillance and hospital data of needlestick and sharps injuries among health workers in 2 university hospitals in Croatia for the period 2018-2022. We compared the pre-COVID-19 pandemic period (2018-2019) with the pandemic period (2020-2022) using descriptive statistics and chi-square tests. P < 0.05 was considered statistically significant. Results:Between 2018 and 2022, a total of 3554 needlestick and sharps injuries were reported among the health care workers. Needles accounted for 2373 (68.6%) of 3458 reports with complete data on injury type. Nurses and medical technicians were the most affected group, accounting for 2358 of the national reports (51.4%; 95% confidence interval 49.7-53.0). Injury reports were higher during the COVID-19 pandemic than before the pandemic (1930 vs 1624). The difference between the 2 hospitals was not statistically significant (P = 0.41). Conclusion:Needlestick and sharps injuries remain an important occupational risk among health care workers in Croatia, particularly among nurses and medical technicians. Safer handling of sharps, better reporting compliance and targeted education can help reduce this occupational exposure.

The field of anesthesia and intensive care is an essential component of modern healthcare. It significantly impacts patient outcomes in elective and emergency medical settings. Integrating anesthesia and intensive care practices is crucial for patient survival, recovery, and overall healthcare efficiency. Despite their importance in clinical settings, there is a lack of scientific and published work in this field of expertise, particularly in smaller countries. This significant gap requires establishing a new national and regional journal focused on anesthesia and intensive care medicine. Such a journal should address specific national and regional issues, encourage and promote research, and facilitate collaboration within the community. This article makes a compelling case for establishing a New Journal of Anesthesia and Intensive Care (NJAIC), the Academic Alliance for Anesthesia and Intensive Care Medicine. It outlines its benefits for practitioners, researchers, and healthcare institutions. Keywords: Journal, Anesthesia, Intensive Care Medicine

Background. Hyperglycemia and insulin resistance are common in critically ill patients, resulting in increased morbidity and mortality rates. Although tight glycemic control can reduce complications, the optimal target blood glucose level remains unclear. This study evaluated an individualized, nurse-driven glycemic protocol in a surgical intensive care unit, with the primary outcome of increased time spent in the “cumulative time in the band”. Methods. This study was conducted in the Surgical Intensive Care Unit and included surgical patients over 18 years of age with diabetes, an APACHE II score greater than 15, and those requiring postoperative intensive care. The protocol group followed a nurse-driven glycemic control protocol using a dynamic algorithm for insulin administration. In the control group, insulin was administered at the physician's discretion. Blood glucose levels were monitored every 2 hours, aiming for 8-11 mmol/L. Data from 53 protocol group patients and 37 control group patients were analyzed. Results. The protocol significantly reduced the episodes of moderate-to-severe hypoglycemia compared to the control group. The primary outcome, cumulative time in the target glycemic range, was significantly improved in the protocol group. Additionally, the modified glycemic penalty index indicated better performance in the protocol group than in the control group. Conclusion. An individualized, nurse-driven glycemic protocol is a safe and effective method for managing hyperglycemia in critically ill surgical patients, improving the time spent in the target glycemic range without increasing the risk of hypoglycemia. These findings support further research on closed-loop algorithms and lower target values.

BACKGROUND Current guidelines differ in their recommendations regarding the use of physiologic transfusion triggers to guide transfusion practice. Data on the interaction between haemoglobin (Hb) and physiologic transfusion triggers, or their response to packed red blood cell (pRBC) transfusions are limited. OBJECTIVES This study aimed to evaluate the interactions between Hb, mixed/central venous oxygen saturation (SvO(2)) and lactate levels as well as their changes (Delta SvO(2), Delta lactate) in response to pRBC transfusion in cardiac surgery patients. DESIGN Retrospective exploratory data analysis. SETTING A 22-bed intensive care unit (ICU) at a single tertiary academic centre and university hospital in Austria. PATIENTS Adult (age >= 18 years) patients who underwent cardiac surgery. MAIN OUTCOME MEASURESPearson correlation coefficients (r) and coefficients of determination (r2) between Hb, mixed/central venous oxygen saturation (SvO2), and lactate levels. Pearson correlation coefficients (r) and coefficients of determination (r2) between Delta SvO2, Delta lactate and pretransfusion Hb. RESULTS A total of 5025 cardiac surgery patients, in whom 20 542 blood gas analyses were performed, were included in the final analysis. Correlations between Hb levels and SvO2 (r2 = 0.026, P < 0.001) and between Hb and lactate levels (r2 = 0.001, P < 0.001) were statistically significant but weak overall. No correlations were found between Delta SvO2 (r2 = 0.002, P = 0.13) or Delta lactate (r2 = 0.003, P = 0.087) and pretransfusion Hb levels. CONCLUSIONS Hb, SvO(2) and lactate levels were only weakly correlated with each other, and changes in SvO(2) and lactate levels in response to pRBC transfusion did not correlate with pretransfusion Hb. Our findings question the usefulness of SvO2 and lactate levels as physiologic transfusion triggers to guide transfusion practice in cardiac surgery patients. TRIAL REGISTRATION Johannes Kepler University Ethics Committee Study Reference Number 1063/2023.

Epstein-Barr virus (EBV) infection and various chemokines, including CCL20, CXCL8 and CXCL10 are considered to participate in the pathogenesis of multiple sclerosis (MS), and several studies point to a direct regulatory effect of EBV on the expression of these chemokines. In our study we hypothesized that serum concentrations of CCL20, CXCL8 and CXCL0 are induced in patients with relapsing-remitting MS (RRMS) in comparison to healthy individuals, and that they are associated with EBV infection. Serum concentrations of CXCL8 and CXCL10 were lower in RRMS patients in relapse in comparison to healthy controls. Although potential effects of corticosteroid therapy introduced in a subgroup of RRMS patients prior to sampling were excluded by subgroup comparison, this possibility has to be considered while interpreting the results. We found an inverse association between serum concentrations of CXCL8 and anti-Epstein-Barr Virus Nuclear Antigen (EBNA) IgG and decreased expression of CXCL8 in peripheral blood mononuclear cells (PBMC) in relapse compared to remission. Lower serum concentrations of CXCL8 and CXCL10 in RRMS patients and decreased peripheral production of CXCL8 in relapse may indicate compensatory anti-inflammatory counter-regulation in MS.

Background and aim The most important multidrug-resistant (MDR) bacteria are extended-spectrum β-lactamase (ESBL) and carbapenem-resistant Enterobacterales (CRE), Acinetobacter baumannii (CRAB), Pseudomonas aeruginosa (CRPE), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus spp (VRE). We evaluated the MDR bacteria in surgical ICUs in the tertiary hospital in Croatia. MATERIAL AND METHODS The antibiotic susceptibility testing was performed by disk-diffusion and broth dilution method. Double disk synergy test and inhibitor based test with clavulanic acid were applied to screen for ESBLs. Transferability of resistance traits was determined by conjugation. The nature of ESBL, carbapenemases, and fluoroquinolone resistance determinants was investigated by PCR. RESULTS 119 MDR isolates were analysed: 41 Klebsiella pneumoniae, 38 Acinetobacter bambini, five Pseudomonas aeruginosa, four Proteus. mirabilis, three Escherichia coli, two Enterobacter cloacae, and thirteen MRSA and VRE, respectively.Phenotypic tests were positive in 37 K. pneumoniae and all E. cloacae and E. coli isolates indicating production of an ESBL. Hodge test and CIM were positive in all but one strain, consistent with the carbapenemase production. Ertapenem resistance was transferable from 12 isolates positive for OXA-48 carbapenemase. PCR detected OXA-48 carbapenemase carried by IncL plasmid, in 34 K. pneumoniae, and one E. cloacae and E. coli isolate respectively, and NDM in three K. pneumoniae isolates. OXA-48 positive isolates coharboured ESBLs belonging to CTX-M family. All A. baumannii isolates tested positive for OXA-23 carbapenemase, whereas four P. aeruginosa produced VIM-2. CONCLUSIONS OXA-48 was the dominant resistance trait among K. pneumoniae isolates, while OXA-23 was the only carbapenemase among A. baumannii isolates.

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.

The prevalence of migraine is higher in women than in men, with female to male ratio 3:1 in reproductive age. It is believed that sex hormones play significant role in migraine pathogenesis. Therefore, treatment of migraine in women has some specificities due to hormonal differences between sexes and due to hormonal fluctuations during menstrual cycle, pregnancy, lactation and perimenopause. Treatment of migraine during pregnancy depends on safety profile of the therapy. NSAID-s like naproxen and ibuprofen are being considered safe during the second trimester, but during the first and third trimester they may have adverse effects on pregnancy and foetus. CGRP antagonists should be avoided during pregnancy. Acetaminophen, ibuprofen, and diclofenac are considered to be safe acute therapy during breastfeeding and for preventive treatment propranolol should be used as first line therapy. Women with severe menstrual and menstrual related migraine without aura may be treated with hormonal therapy, whereas it should be avoided among patients with aura due to increased risk of stroke.

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.

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.

Difficult airway management usually refers to intubation or extubation problems. We present a case report of difficult extubation, and airway management algorithm that was used in a female patient following parotidectomy. Although there are algorithms for difficult airway management, there are no recommendations for difficult extubation that is mechanically caused and where endotracheal tube cannot be easily removed. Such conditions are rarely mentioned in the literature,usually in the form of case reports. Inability to remove endotracheal tube due to mechanical causes is an urgent condition and calls for an algorithm and guidelines. The algorithm that was performed in this case went uneventfully, and the patient recovered well.

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.

Invasive fungal infections (IFI) are an important problem of modern medicine. The reason is growing population of immunocompromised patients and high morbidity and mortality of these infections. Timely diagnosed IFI is of utmost importance because the delay of antifungal treatment has impact on treatment outcome. Cultivation as a conventional diagnostic method has low sensitivity, long duration and demands obtaining invasive samples. Therefore, in the last two decades fungal biomarkers are investigated for earlier and more sensitive diagnostics. 1,3-β-D-glucan (BDG) is a fungal biomarker in patients’ sera that enables detection of the following fungal pathogens: Candida spp., Aspergillus spp., Acremonium, Coccidioides immitis, Fusarium spp., Histoplasma capsulatum, Trichosporon spp., Sporotrix schenckii, Saccharomyces cerevisiae and Pneumocystis jirovecii. Low level and absence of BDG in the cell wall unables the detection of Cryptococcus spp. and order Mucorales with this test. High negative predictive value of BDG can be used when deciding to stop antifungal treatment and be a part of strategy for antifungal stewardship in intensive care units. In hematological patients BDG can be used as a screening method or as a part of diagnostic work-up when IFI is suspected. Reliability of test result is higher when two or more consecutive samples are positive. Influence of antifungal prophylaxis on BDG test results is still unclear. BDG kinetics and its relation to clinical outcome are still investigated. For pediatric population cut-off values for interpretation are still not defined, although many studies have been published investigating this issue. Although still not recommended by pediatric guidelines, this test can help in certain situations having in mind its limitations. BDG as a fungal marker represents the significant progress in IFI diagnostics. With simultaneous application of other diagnostic methods, exact interpretation and rational use, it can help earlier and more successful diagnostics and treatment of IFI.

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