Savinova, Darija

Dėl galimų komplikacijų ir paciento saugumo operacijos metu, labai svarbu anestezijos metu tinkamai stebėti pa­ciento gyvybinius parametrus. Gydytojas, remdamasis klinikiniais įgūdžiais, turi vertinti paciento fiziologinius parametrus: kvėpavimo dažnį, jo efektyvumą, širdies ir kraujagyslių sistemos rodiklius. Šiuolaikinėje medicinoje paciento stebėjimui gydytojas turi vadovautis privalo­maisiais monitoravimo standartais. Užtikrinus reikiamą minimalų monitoravimą, jei reikia ir yra galimybė, gy­dytojas gali jį išplėsti.

Funkcinė endoskopinė sinusų operacija atliekama siekiant pašalinti patologiškai pakitusią sinusų gleivinę ar darinius. Chirurgams išvengti gyvybei grėsmingų komplikacijų, susijusių su kaukolės pamato chirurgija, labai svarbus geras operacinio lauko matomumas. Operacijos metu (prieš ar per anesteziją) siekiant sumažinti gerai vaskuliarizuotos gleivinės gausų kraujavimą, naudojami įvairių grupių vaistai. Šios integruotos literatūros apžvalgos tikslas − apibūdinti kraujavimo valdymo endoskopinių sinusų operacijų alternatyvas. Paieška buvo atlikta PubMed duomenų bazėje, kuri apėmė klinikinius tyrimus, susijusius su sistemiškai ir lokaliai veikiančiais vaistais ir jų veiksmingumu kontroliuojant kraujavimą iš sinusų gleivinės. Literatūros apžvalgoje pateikiami tyrimai bei rezultatai vertinami gerai. Atlikti tyrimai su preparatais rodo teigiamos dinamikos ženklus, operuojant pacientus, tačiau lyginant vaistus, ne visi yra vienodai efektyvūs. Atsižvelgiant į šiame tyrime pateiktas analizes, daroma išvada, jog tam tikros tiriamos vaistų grupės pagerina kraujavimo kontrolę operacijų metu ir operacinio lauko matomumą chirurgams.

Introduction: Brain abscess is often a localized brain infection, requiring prompt surgical intervention and high-dose antibiotic therapy. In most cases, brain abscesses are caused by a contiguous spread of infections, such as sinusitis or otitis. We present a case report of patient with pneumonia complicated by a brain abscess. Case report: A 58-years-old man presented to his local hospital with symptoms of dyspnoea, fever around 39.5°C and disorientation lasting for five days. Laboratory investigation revealed high inflammatory markers. The chest X-ray (CXR) showed lung infiltration on the left. Patient was admitted to the Intensive care unit (ICU) with severe respiratory failure and was intubated because of hypercapnia, hypoxemia and acidosis. Treatment with cefuroxime was started. The next day, inflammatory markers increased and cefuroxime was changed to ampicillin-sulbactam. Computed tomography (CT) scan revealed abscess in right frontal lobe and edema near the corpus callosum. Patient was emergently transferred to the Neurosurgical center of the university hospital for further care. There he underwent urgent stereotactic puncture of the intracerebral abscess, about 7 ml of yellow-green pus gushed out and a pus sample was collected during the operation. During surgery, ventriculitis was suspected and external ventricular drainage was formed. The patient was treated with ceftriaxone, vancomycin and metronidazole combination. He remained critically ill, with abscessed pneumonia on both sides, unstable hemodynamics and shock. Head CT was repeated: intracerebral abscess with positive dynamics, but was found ischemic lesions of cerebellar. Abdominal and chest CT was performed, showing abscesses of the lungs, pleura and thrombosis of the splenic artery. Clindamycin was additionally administered as sepsis and Multiple Organ Dysfunction Syndrome (MODS) progressed. Despite treatment, shock and hypoxemia deteriorated with 2 vasopressors at maximum doses. On the third day, the patient died without response to cardiopulmonary resuscitation. Conclusions: Brain abscess is a focal infection that originates from locally inflamed areas of the brain parenchyma and develops into a collection of pus surrounded by a well-vascularized capsule. It is a rare but severe disease and can result in severe disability or even death, especially if misdiagnosed or improperly managed.

Introduction: Acquired hemophilia A (AHA) is a rare disease of the coagulation system caused by autoantibodies to clotting factor VIII (FVIII) with no personal or family history of diseases related to coagulation. In this thesis, we present a case of AHA complication, which presented with intracranial hemorrhage. Case report: A 61-year-old man presented to his local hospital with symptoms of disorientation. The day before he complained of severe headache and increased blood pressure. The patient’s Glasgow Coma Scale (GCS) was 9 (E2; V2; M5). Computed tomography (CT) scan revealed a possible rupture of anterior choroidal artery aneurysm. The patient was sedated, intubated, and emergently transferred to the Neurosurgical center of the university hospital. Clinical examination revealed hematomas at the site of injection on the forearms. Laboratory investigation showed anemia, an activated partial thromboplastin time (aPTT) of 86.0 s. Liver function tests were within the normal ranges. Urgent head CT revealed signs of obstructive hydrocephalus and intraventricular hemorrhage. CT angiography (CTA) showed no aneurysms. The patient was admitted to the Neurointensive care unit. Due to the observed increase in the aPTT and suspected coagulopathy two units of fresh frozen plasma was infused before the surgery. The patient underwent placement of a right external ventricular drain. Next day, the coagulation tests were available, which revealed a reduction in FVIII activity (1%). The patient was prescribed with activated prothrombin complex concentrate and methylprednisolone. Red blood cell transfusion was performed. Later CT scan demonstrated hemorrhages in the brainstem, signs of cerebral edema and herniation. Further surgery was not considered due to his difficult condition. Sedation was discontinued and hemodynamics was maintained with noradrenaline. Following day CTA was performed and results showed no intracerebral blood flow in any of major arteries of the brain. The patient died on the 4th hospital day. Conclusions: Intracerebral hemorrhage is a severe complication that is relatively common among patients with hemophilia. Most patients are diagnosed with AHA on the basis of prolonged aPTT and additional tests after massive bleeding. If the patient delays going to hospital and arrives without an established clotting disease, even with appropriate treatment, the outcome can be fata capsule. It is a rare but severe disease and can result in severe disability or even death, especially if misdiagnosed or improperly managed.

Introduction: Intravenous (IV) amiodarone is often used for the treatment of atrial arrhythmias. Amiodarone restores sinus rhythm in critically ill patients with hemodynamically unstable atrial fibrillation (AF), also can be used for rate control in ill patients with AF with rapid ventricular response in whom the tachycardia is contributing to hemodynamic compromise. In this thesis, we present a case of unstable AF, which was controlled by using amiodarone. Case presentation: A 73 years old woman presented to her local hospital because of nausea and weight loss, which had been bothering her for 2 months. She had also chronic AF as a concomitant disease. Computed tomography (CT) scan revealed malignant pancreatic tumor. She was transferred to our hospital for further care. The next day, 2000ml of gastric stasis was drained and the patient underwent oesophagogastroduodenoscopy (OGD) under general anaesthesia. During OGD patient demonstrated ventricular fibrillation (VF). Cardiopulmonary resuscitation was started, circulation was restored in 5 minutes and patient was transferred to intensive care unit (ICU). Tachysystolic AF (heart rate 200 beats per minute (BPM)) was found in ICU and 600 mg of amiodarone infusion was started with addition of 0,5mg of digoxin IV. Next day, whilst hemodynamics stable OGD attempted once more. Before the start of procedure, tachysystolic AF (HR 200BPM) was observed on the monitor and the procedure was abandoned. Hemodynamics was stabilised by digoxin IV and patient returned to the ICU. After two unsuccessful attempts of OGD, multidisciplinary team consisting of cardiologist, anesthesiologist and intensivist decided to saturate the patient with amiodarone before the procedure to slow down the HR<100 BPM. Patient had infusion of 450 mg IV during30min, 1350 mg IV during next 24h. After reaching a HR <100BPM OGD was repeated successfully. The next day patient was returned to her local hospital in stable condition. Conclusion: Amiodarone is the most commonly prescribed anti-arrhythmic drug for patients with AF. This is due to its particular electrophysiological properties and anti-arrhythmic effects. Using amiodarone can help to stabilize hemodynamic and HR.

Viena iš rizikingiausių chirurginės intervencijos komplikacijų yra kraujavimas. Tyrimo tikslas − išsiaiškinti koaguliacinės sistemos vertinimo svarbą ir galimybes priešoperaciniu laikotarpiu. Atlikta mokslinių studijų apžvalga ir analizė. Straipsnių ieškota tarptautinėse medicinos duomenų bazėse PubMed, Wiley, Springer. Atrinkta ir išnagrinėta 13 straipsnių anglų kalba, kurių pavadinimas, santrauka ir raktažodžiai bei jų deriniai atitiko tyrimo temą. Tyrimo rezultatai ir išvados. Dėl galimų komplikacijų ir kraujavimo rizikos operacijos metu, labai svarbu tinkamai ištirti pacientą priešanestetiniu laikotarpiu. Būtina surinkti išsamią anamnezę apie rizikos veiksnius: šeiminę anamnezę, vaistų vartojimą, kraujavimą po intervencijų, hematomas ir kitas būkles. Šiuolaikinėje medicinoje paciento įvertinimui rekomenduojama naudoti glaustus ir aiškiai suprantamus klausimynus, kurie padeda korektiškai įvertinti jo būvį. Ne mažiau svarbi ir ligonio apžiūra bei laboratoriniai tyrimai, kurie papildo surinktą anamnezę ir padeda įvertinti kraujavimo riziką. Atlikus išsamų paciento įvertinimą ir neradus kraujavimo priežasties, rekomenduojama atlikti genetinius tyrimus dėl paveldimų koagulopatinių būklių.

Opioidai – vieni dažniausiai stipraus skausmo malšinimui vartojamų medikamentų. Nepaisant stipraus analgezinio poveikio, ši medikamentų grupė sukelia ir šalutinių reiškinių, tokių kaip silpnumas, pykinimas ar vėmimas,haliucinacijos, priklausomybė ir hiperalgezija. Pastarosios būklės veikimo mechanizmas dar nėra iki galo suprantamas, tačiau manoma, jog jis susijęs su glutamato receptorių aktyvavimu ir glutamato nešiklių slopinimu.Siekiant išvengti opioidinės hiperalgezijos, svarbu suprasti skirtumus tarp šios būklės ir tolerancijos bei abstinencijos, šviesti visuomenę apie neigiamą opioidų poveikį,kai reikia, suteikti pagalbą ir rinktis kitus veiksmingus nuskausminimo metodus.

Introduction In modern surgery, with the rapid introduction of new surgical techniques and enhanced recovery protocols, it is particularly important to maintain acceptable postoperative pain intensity using the lowest possible doses of morphine. The search for methods for reduction of postoperative opioid requirements is constantly evolving [1]. Ketamine is one of the most attractive additives to achieve these goals, but the exact dose of ketamine is still not accurate[2,3]. Aim Assess the significance of low dose ketamine (0,3mg/kg by LBM (lean body mass)) for postoperative morphine requirements and side effects in patients after remifentanil anaesthesia in bariatric surgery. Methods A prospective, randomized (random number generator), double-blind, placebo controlled study. The study included 47 patients, who underwent bariatric surgery at HLUHS. Following informed consent adult obese patients up to ASA class III undergoing laparoscopic gastric bypass with remifentanil anaesthesia were given equal volume (5 ml) of study medication: single dose of ketamine 0,3 mg/kg (test, group K=30) or saline (control, group S=17) at anaesthesia induction. Study medication was prepared by anaesthesia provider not involved in postoperative care of patients. Postoperatively pain intensity, morphine requirements and side effects were recorded every 15min up to 155 minutes in postanaesthesia care unit. Results The pain intensity was similar in both groups in all points of observation (p=0,05-0,973). […].

Introduction Safe and rapid recovery of patients after anaesthesia is one of the important factors for good operating room turnover. Intraoperative low dose ketamine is an attractive adjuvant to traditional pain management protocols enabling to reduce opioid consumption and side effects of them. (1) However, the rate of recovery of patients after anaesthesia must also be taken into account when developing methods of anaesthesia and postoperative analgesia. (2) Aim Assess the significance of low dose ketamine for early postanaesthesia recovery of obesepatients by comparing postoperative recovery time and vital signs. Methods A prospective, randomized, double-blind, placebo-controlled study. The study included 53 bariatric patients undergoing laparoscopic gastric bypass with remifentanil-based anaesthesia in HLUHS. Patients were given 0,3 mg/kg for lean body mass (LBM) ketamine (test, group K=23) or placebo injection (control, group S=30) during anaesthesia induction. Vital signs (arterial blood pressure (BP), heart rate, saturation (SpO2)) were evaluated postoperatively every 2 minutes after termination of remifentanil infusion as well as spontaneous respiration recovery time, time of extubation, eye opening, recovery of orientation and beginning of response to verbal command. […].

SARS-Cov-2 sukelta pandemija skatino ieškoti Covid-19 gydymo būdų. Ligos progresavimas susijęs su sunkia uždegimine būkle, todėl dauguma tiriamų vaistų yra tiesiogiai ar netiesiogiai susiję su imunosupresijos mechanizmais. Šios integruotos literatūros apžvalgos tikslas − apibūdinti imunosupresinių terapijų taikymo Covid-19 alternatyvas. Mokslinių straipsnių paieška buvo atlikta PubMed duomenų bazėje, kuri apėmė klinikinius tyrimus, susijusius su pirmine imunosupresine terapija ir jos veiksmingumu, kovojant su koronavirusu. Literatūros apžvalgoje pateikiami tyrimai bei rezultatai vertinami kontroversiškai. Atlikti tyrimai su vaistiniais preparatais rodo teigiamos dinamikos ženklus, gydant pacientus, sergančius sunkia koronaviruso forma, tačiau dalyje šių tyrimų trūksta pakankamos pacientų imties. Atsižvelgiant į šiame tyrime pateiktą analizę, daroma išvada, jog tiriami imunosupresinis bei imunomoduliacinis gydymo metodai teikia vilčių, kovojant su Covid-19 infekcija.