Papers by Radmilo Jankovic
Response: We appreciated very much the constructive comments from the editor and the reviewers an... more Response: We appreciated very much the constructive comments from the editor and the reviewers and are thankful for the effort and time spent in the revision of the manuscript. Please find below the detailed point-by-point responses to all comments. Since the reordering and restructuring of the manuscript was substantial, we have written bullet points of our major changes to the manuscript, rather than included a 'track changes' document.
Intensive Care Medicine, 2020
Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. ... more Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICUacquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9-27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6-16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score < 19, ICU stay > 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2-1.8), stage II (OR 1.6; 95% CI 1.4-1.9), and stage III or worse (OR 2.8; 95% CI 2.3-3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat.
Intensive Care Medicine, 2019
Purpose: To describe the epidemiology of intra-abdominal infection in an international cohort of ... more Purpose: To describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock). Methods: We performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis. Results: The cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospitalacquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation.
Trials, 2019
Background: Postoperative pulmonary complications (PPC) may result in longer duration of in-hospi... more Background: Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. Methods: PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m 2 , and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH 2 O with lung RM, or PEEP of 5 cmH 2 O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion: PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery.
The Lancet. Respiratory medicine, Jan 14, 2018
Results from retrospective studies suggest that use of neuromuscular blocking agents during gener... more Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adju...
Serbian Journal of Anesthesia and Intensive Therapy, 2016
Uvod: Survivin (BIRC5) je pripadnik familije proteina inhibitora apoptoze i ima izuzetno važnu ul... more Uvod: Survivin (BIRC5) je pripadnik familije proteina inhibitora apoptoze i ima izuzetno važnu ulogu u takozvanoj tački bez povratka ćelijske apoptoze. Već je dokazana uloga survivina u nastanku tumora i autoimunih oboljenja, međutim sve je više dokaza da je takođe senzitivan na postojanje prethodnog ishemijskog oboljenja srca. Metode: U ovu prospektivnu pilot studiju je uključeno 78 pacijenata koji su se pripremali za jednu od opsežnih nekardiohirurških operacija. Krv je uzorkovana unutar 7 preoperativnih dana, izdvojen je serum i zamrznut na-70оC. Merenje količine survivina u serumu je sprovedeno ELISA (Enzyme-linked immunosorbent assay) metodom, a rezultati su očitavani na aparatu DIAREADER Elx800G. Rezultati: Pacijenti su bili prosečne starosti 71,46 ± 6,87 godina, dok je medijana survivina iznosila 4,56 (0,00-76,78) pg/ml. Survivin se pokazao kao odličan prediktor postoperativne smrtnosti (P < 0,05, ROC/AUC = 0,807). Pacijenti su zatim podeljeni u dve grupe, grupu pacijenata obolelih od tumora i grupu pacijenata koji nisu oboleli od tumora. U obe grupe je urađena statistička analiza podataka (P
Canadian Journal of Physiology and Pharmacology, 2019
Application of cisplatin (CP) for the treatment of different cancers is known to cause pancreatit... more Application of cisplatin (CP) for the treatment of different cancers is known to cause pancreatitis through an increase in reactive oxygen species production and promotion of inflammation. Caffeic acid phenethyl ester (CAPE), the main activity carrier of propolis extracts, was previously found to possess numerous beneficial properties. This study aims to determine for the first time the potential of CAPE in preventing CP-induced pancreatic tissue damage by studying the changes occurring on both biochemical and microscopic levels. The levels of serum α-amylase and a panel of pancreatic tissue biomarkers related to tissue injury (reduced glutathione, xanthine oxidase, malondialdehyde, and protein carbonylated concentration) and inflammation (myeloperoxidase, nitric oxide, and umor necrosis factor alpha) were studied in male Wistar rats treated with either CP alone or with CP and CAPE. Additionally, microscopic analysis of pancreatic tissue would be conducted as well. Application of CA...
Aging Clinical and Experimental Research, 2017
When combined with individual biomarkers AUC of ACS NSQIP raised, but if we combined all three bi... more When combined with individual biomarkers AUC of ACS NSQIP raised, but if we combined all three biomarkers with ACS NSQIP, AUC reached as much as 0.920 for heart complications and 0.939 for mortality. Discussion ACS NSQIP proved to reduce inaccuracy in preoperative assessment, but it cannot be used independently, which has already been proved by other authors. Conclusions Our results indicate that ACS NSQIP represents an accurate tool for preoperative assessment of elderly patients, especially if combined with cardiac biomarkers.
Turkish journal of anaesthesiology and reanimation, 2017
There is still a lack of a universally applicable and comprehensive scoring system for documentin... more There is still a lack of a universally applicable and comprehensive scoring system for documenting the invasiveness of surgical procedures. The proposed preliminary 'Universal Surgical Invasiveness Score' (pUSIS) is intended to fill this gap. We used the recently developed pUSIS to obtain values from 8 types of surgery and 80 individual interventions. The results were analysed using descriptive statistical methods. The degree of difficulty on a scale from 0 (very easy) to 10 (extremely difficult) and time expenditures for assessing pUSIS were documented. Individual pUSIS values ranged from 8 in a laparoscopic cholecystectomy case to 36 in a total hip replacement case. The lowest median pUSIS value of 11.5 was found for laparoscopic cholecystectomy and the highest value of 24.5 was found for open thoracic surgery. The correlation between pUSIS values and the duration of surgery resulted in a tight linear regression (R2=0.6419). The lowest mean (±SD) difficulty level to obtain...
Minerva anestesiologica, Jan 30, 2016
European Society of Cardiology (ESC)/ European Society of Anesthesiology (ESA) highlighted that a... more European Society of Cardiology (ESC)/ European Society of Anesthesiology (ESA) highlighted that anesthesiologist has a leading role in perioperative cardiovascular assessment and management in the year of 2014. During cardiovascular assessment one can rely on cooperation of multi-disciplinary specialists like: other anesthesiologists, cardiologists and surgeons. For the purpose of precise systematization and decision making the Lee score or NSQUIP database can be used besides the traditionally used ASA score. Additional help is provided with specific palette of cardiac biomarkers like: cTnT, cTnI, CRP, NT-proBNP, BNP, etc. Biomarkers are considered to represent a foundation of Evidence Based Medicine and they help anesthesiologists in the decision-making process. They increase the possibilty to achieve the best clinical outcome for each patient. An ideal biomarker doesnt exist and therefore new research are currently being conducted with the aim to find and declare more specific bio...
Serbian Journal of Anesthesia and Intensive Therapy, 2016
Istraživanja u okviru The 5th National Audit Project (NAP5) su utvrdila da se prisustvo slučajne ... more Istraživanja u okviru The 5th National Audit Project (NAP5) su utvrdila da se prisustvo slučajne svesti tokom opšte anestezije dešava jednom u 15414 slučajeva. Ukupno oko dve trećine slučajnih svesti tokom opšte anestezije se dešavaju tokom takozvanih dinamičnih faza anestezije. Prisustvo svesti obično jako kratko traje, što ukazuje na to da monitoring mora biti osposobljen da detektuje čak i kratke faze svesti. Administracija neuromišićnih blokatora otežava monitoring svesti, te se najpouzdanijim monitoringom smatraju: izolovana tehnika nadlaktice, BIS monitoring i održavanje ETAG iznad 0,7 MAC. Svakako ni jedna od ovih metoda se ne sme koristiti izolovano od iskustva anesteziologa i kliničkih metoda za procenu stanja svesti tokom opšte anestezije.
BioMed Research International, 2015
Preoperative assessment of cardiovascular risk is essential when it comes to extensive noncardiac... more Preoperative assessment of cardiovascular risk is essential when it comes to extensive noncardiac surgery procedures. Therefore, accurate and timely diagnosis of myocyte damage is vital. In modern medical practice it is believed that the so-called “multimarker” approach is the most appropriate and most accurate, but new research points out that there are novel biomarkers which could be used independently. Studies that evaluate miRNA, H-FABP, and MR-PAMP give encouraging results. When it comes to miRNA clinical studies show high statistical significance, especially in the case of acute myocardial infarction (P=0.001). Statistical significance ofP=0.007was found in acute coronary syndrome, when H-FABP was measured. Biochemical marker MR-PAMP showed statistical significance ofP<0.0001in most clinical studies.
The porphyrias are a group of rare enzymatic defects of haem biosynthesis. These defects lead to ... more The porphyrias are a group of rare enzymatic defects of haem biosynthesis. These defects lead to an accumulation of haem's precursores, the porphyrins, in some tissues and in the excreted matter (urine and feces). Of most importance for anaesthesiology practice are acute hepatic porphyrias. The acute crisis of porphyria are often presented with severe abdominal pain, neurological and mental disorders, and autonomic nervous system involvement in a form of tachycardia, hypertension and excessive sweating. Respiratory and bulbar paralysis are potentially fatal complications of the disease. A number of medications, including anaesthetics, can precipitate the acute attack of porphyria. The role of the anaesthesiologist is to adequately prepare these patients for a surgery, to use suitable anaesthetics and other medications in perioperative period, to provide necessary monitoring, and to recognize and treat possible complications without delay.
INTRODUCTION.Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition with an ove... more INTRODUCTION.Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality rate of 65%. Massive haemorrhage requires infusion of fluids that do not contain clotting factors which develops dilutional coagulopathy. Rotational thrombelastometry (ROTEM) permits differential diagnosis of the underlying pathomechanism of coagulopathy. PCC showed much efficiency in the treatment of intraoperative massive bleeding . CASE REPORT. A 79-year-old man was addmited to Vascular Surgery Department, Clinical center in Nis as an emergency with the symptoms of AAA rupture. After resuscitation he was trasported to the operation room (Hgb: 45 g/L, HCT: 15%, BP: 80/40 mmHg). Massive infusion of crystalloids, colloids and plasma expanders kept the patient hemodinamically stable but led to dilutional coagulopathy. Transfusion of platelets, cryoprecipitate and fresh-frozen plasma (FFP) were provided together with tranexamic acid. Total blood loss during the surgery was 5...
Summary. Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall... more Summary. Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality rate of 65%. Massive haemorrhage requires infusion of fluids that do not contain clotting factors which develops dilutional coagulopathy. Rotational thrombelastometry (ROTEM) permits differential diagnosis of the underlying pathomechanism of coagulopathy. Prothrombin complex concentrate (PCC) showed efficiency in the treatment of intraoperative massive bleeding. Case report: A 79-year-old patient was addmited to hospital as an emergency with the symptoms of AAA rupture. After resuscitation he was trasported to the operation room (Hgb: 45 g/L, HCT: 15%, BP: 80/40 mmHg). Massive infusion of crystalloids, colloids and plasma expanders kept the patient hemodinamically stable but led to dilutional coagulopathy. Transfusion of platelets, cryoprecipitate and fresh-frozen plasma (FFP)were provided together with tranexamic acid. Total blood loss during the surgery was 5L and 1.85L was ...
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Papers by Radmilo Jankovic