Perioperative complications of esophagectomy - prevention, diagnosis and management

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.

Early physical therapy in mechanically ventilated, critically ill patients

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.

Early physiotherapeutic interventions in Intensive Care Units

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.

Sepsis in children: Initial assessment and treatment

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.

Analgesia and sedation in surgery Intensive Care Unit (ICU)

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.

Supportive therapy of sepsis in children

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.

Early treatment and intensive care of children with burn injury

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.

Central venous pressure up date: What is it good for?

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.

Stress-induced cardiomyopathy in aneurysmal subarachnoid hemorrhage

Introduction: Neurogenic stunned myocardium is well described after aneurysmal subarachnoid hemorrhage. Stress-induced cardiomyopathy (takotsubo cardiomyopathy) is a form of neurogenic stunned myocardium which is not common after subarachnoid hemorrhage. We describe a case report of stress-induced cardiomyopathy (takotsubo cardiomyopathy) after aneurysmal subarachnoid hemorrhage. Case report: A previously healthy postmenopausal woman suffered aneurysmal subarachnoid hemorrhage with consequent hydrocephalus. After external ventricular drainage, craniotomy and aneurysm of the posterior inferior cerebellar artery clipping, patient developed signs of acute coronary syndrome with heart failure. Transthoracic echocardiogram showed left ventricular apical ballooning and hypercontractile basal segments. On chest radiography bilateral pulmonary infiltrates were seen. Mechanical ventilation and continuous sedation were started. Five days after, patient was weaned from mechanical ventilation and extubated. On control echocardiogram, the signs of apical ballooning syndrome resolved. Conclusions: This case and review of the literature suggest stress-induced cardiomyopathy can mimic acute coronary syndrome after aneurysmal subarachnoid hemorrhage.

Traumatic pancreatitis in children

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.