Perioperative bleeding management is a complex task which has significant impact on surgery outcome. Most hemostasis disorders occurring intraoperatively are acute, caused by massive bleeding, and can be explained by the principle of loss, compensation, and dilution of circulating blood volume. Disorders at the level of the hemostatic system can be assessed both by various standard laboratory tests, such as: prothrombin time, activated partial thromboplastin time, platelet count, coagulation factor concentrates, levels of antithrombin and D-dimer; or by point-of-care (POC) methods. Standard laboratory tests have their limitations. They do not detect increased intraoperative bleeding tendency, and it is recommended to use methods such as POC, which quickly and accurately assess the patient's coagulation status, thus enabling the administration of the appropriate therapy, as soon as possible. The most commonly used POC methods are the aggregometry methods (Multiplate, PFA-100, and Platelet Mapping Assay), used in perioperative platelet function evaluation, and viscoelastic tests (rotational thromboelastometry-ROTEM; thromboelastography-TEG), which provide a graphic representation of all hemostatic activity by measuring the time elapsed until the onset of clot formation, formation dynamics, as well as clot firmness and stability over time. The main advantages of the POC method are: the swift availability of results (up to 15 minutes) and the very small blood sample size (up to 5 ml) necessary for performing the test; while the main disadvantages are: their cost, which exceeds the cost of performing standard laboratory tests, and their inability to detect coagulopathies, resulting from the disturbance of the patient's normal physiological state. POC methods are very important in reducing perioperative bleeding, reducing blood transfusions, and forming adequate therapeutic algorithms.
Sepsis is a significant health problem, considering that, annually, over 20 million people fall ill from sepsis. Despite the significant development of medicine in recent decades, the mortality rate of sepsis is exceptionally high (about 26%). The definition of sepsis developed together with the understanding of the mechanism of sepsis. At the beginning of the 1990s, the first definition of sepsis was created, according to which sepsis was defined as systemic inflammatory response syndrome (SIRS), with the presence of suspicion or evidence of infection. Due to many inadequately diagnosed patients with sepsis, another definition was created, according to which sepsis is defined as a clinical syndrome. As the result of the lack of clarity of the previous definitions and the new information on the pathophysiological process of sepsis, a third definition of sepsis was developed in 2016. According to this definition, sepsis is a life-threatening condition based on organic dysfunction resulting from the body's inappropriate response to infection. Septic shock manifests as circulatory, cellular and metabolic instability. It is characterized by a serum lactate level higher than 2 mmol/l and hypotension, which requires vasopressor therapy after the administration of intravenous solutions. This definition of sepsis and septic shock enables early recognition and treatment of patients with sepsis, which are critical steps in reducing the incidence and mortality from this disease.
Delirium is not only a mental change but also a complex clinical syndrome with multiple pathophysiological changes. Delirium is an acute brain dysfunction accompanied by change or fluctuation of basal mental status, loss of attention with disorganized thinking, or altered level of consciousness. Although healthcare professionals realize the importance of recognizing delirium, it frequently goes unrecognized in the intensive care unit. Acute delirium is associated with increased mortality, morbidity, length of stay, and healthcare costs in intensive care units and hospitals. The consequences of delirium are long-term cognitive impairment, functional disability, post-discharge cognitive dysfunction, and institutionalization. Critical illness-related delirium can affect the diagnosis and treatment of primary diseases and disappears with the improvement of primary diseases. In the intensive care unit, delirium has been reported in 40% to 60% of non-ventilated patients and up to 50% to 80% of critically ill patients undergoing mechanical ventilation. Recent investigations have shown that delirium is preventable in 30-40% of cases. Available sedation and delirium monitoring instruments allow clinicians to recognize these forms of brain dysfunction. Multiple management strategies such as ABCDE, eCASH, and ESCAPE are helpful to prevent and treat delirium and improve the prognosis of critically ill patients.
Airway management is a crucial step in treating emergency medical conditions. Numerous complications, which can further worsen the patient's condition, can occur as a result of difficulties in airway management. The most well-known and frequently used tests for assessing the airway in emergencies are the Mallampati class and a series of abbreviated procedures, which are mnemonically called LEMON. They have a significant role in predicting difficult airway management and enabling the medical team to adequately prepare. When securing the airway, it is necessary to provide adequate equipment, monitoring and trained personnel. If an assessment is made that the airway management could prove to be difficult, it is best to follow das algorithms, which not only help doctors secure a problematic airway but also protect them from criminal liability should complications or even death of the patient occur. This way, securing an airway in emergencies can present a very serious, but not insurmountable problem.
Hypertensive crisis represents a medical emergency that demands urgent treatment. There are two kinds of hypertensive crisis (hypertensive emergency and hypertensive urgency), which require different protocols depending on the stage of emergency and type of hypertensive crisis. The diagnosis is not based only on the absolute values of blood pressure, but also on the time of onset. Hypertensive emergency must be promptly treated, within of one hour of its onset, because it may cause serious organ damage; while hypertensive urgency needs to be treated within 24 hours. In order to treat hypertensive emergencies promptly, drugs must be administered via continuous intravenous infusion or intermittent IV boluses of potent vasodilators such as sodium nitroprusside or glyceryl trinitrate, although other groups of drugs are also used. Hypertensive urgency is usually treated with peroral drugs.
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