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Potreba za disanjem tijekom zadržavanja daha rezultira nastankom nevoljnih dišnih pokreta. Ovom se studijom željelo utvrditi pokreću li IBM-e kritične razine hiperkapnije i/ili hipoksije tijekom maksimalne apneje. Zbog toga su određivani plinovi u arterijskoj krvi tijekom maksimalnog voljnog zadržavanja daha. Jedanaest zdravih ispitanika zadržavalo je dah nakon što su prethodno udisali zrak, hiperoksično-normokapničnu, hipoksično-normokapničnu i normooksično-hipekapničnu mješavinu plinova. Prethodno udisanje plinskih mješavina olakšalo je nastup IBM-a, skraćujući vrijeme njihova nastupa za oko 46% (hiperoksični uvjeti), odnosno za oko 80% (hipoksični uvjeti) u usporedbi s prethodnim udisanjem zraka. Zamijećena jaka korelacija (r=0.83, p=0.002) između parcijalnog tlaka ugljičnog dioksida (PaCO2) i trenutka nastupa IBM-a, a nakon prethodnog udisanja hiperoksične i hiperkapnične plinske mješavine, govori u prilog postojanja mogućeg PaCO2 praga za nastup IBM-a, koji iznosi oko 6.5 ± 0.5 kPa. Prag za parcijalni tlak kisika u arterijskoj krvi (PaO2) pri kojem nastupa IBM nije se mogao odrediti. Međutim, zamijetili smo da je nastup IBM-a, tijekom maksimalne apneje, barem djelomice ovisan o međuodnosu PaO2 i PaCO2. Prema tome, ova studija ukazuje na složen odnos između O2 i CO2 u arterijskoj krvi i fiziološkog odgovora na maksimalno zadržavanje daha., The growing urge to breathe that occurs during breath-holding results in development of involuntary breathing movements (IBMs). The present study determined whether IBMs are initiated at critical levels of hypercapnia and/or hypoxia during maximal apnoea. Arterial blood gasses at the onset of IBM were monitored during maximal voluntary breath-holds. Eleven healthy men performed breath holds after breathing air, hyperoxic–normocapnia, hypoxic–normocapnia, and normoxic–hypercapnia. Prebreathing of the gas mixtures facilitated the IBM onset, reducing the time-to-onset for ~46% (hyperoxic condition) and for ~80% (hypoxic condition) compared to the normoxic air breathing time. A strong correlation (R = 0.83, P = 0.002) between arterial partial pressure of CO2 (PaCO2 ) at IBM onset after pre-breathing hyperoxic and hypercapnic gas mixtures was observed, suggesting the existence of a possible IBM PaCO2 threshold level of ~6.5 ± 0.5 kPa. No clear “threshold” was observed for partial pressure of arterial O2 (PaO2 ). However, we observed that IBM onset was influenced, in part, by an interaction between PaO2 and PaCO2 levels during maximal apnoea. This study demonstrated the complex interaction between arterial blood-gases and the physiological response to maximal breath holding.

Background and Goal of Study: Spinal anesthesia is a preferred method of anesthesia for lower limb surgery. Antinociceptive synergism between local anesthetics and opioids is well studied. Dexmedetomidine, selective alpha2-agonist, is relatively new as an intrathecal agent. The main goal of this study was to compare dexmedetomidine with opioids as adjuvant to spinal anesthesia, in terms of its ef fect on postoperative analgesia, as well as its ef fect on hemodynamic stability in elderly patients. Materials and Methods: Spinal anesthesia was performed on thirty ASA Grade II and III geriatric patients undergoing hip surgery. Before the procedure all patients received 500 mL of i.v. saline. Noninvasive blood pressure, heart rate and SpO2 were noted every 5 minutes. NRS(numeric rating scale) was assesed 2, 4, 6, 8, 10 and 12 hours af ter spinal block. Patients were randomly assigned into two groups: control group (n=15) received levobupivacaine by body height nomogram with 2.5 mcg (0.5 mL) of sufentanil, while subject group (n=15) received levobupivacaine by body height nomogram with 5 mcg of dexmedetomidine. Groups were compared by hemodynamic parameters(systolic pressure, pulse) and NRS score in early postoperative stage of recovery. Results and Discussion: Baseline patients’ characteristics were comparable in both groups. Analysis of hemodynamic data showed that incidence of hypotension, defined as systolic blood pressure lower than 90 mmHg, was not significantly dif ferent between groups. When comparing analgesic ef fect, dexmedetomidine showed significantly better analgesic ef fect than opioids 10 and 12 hours af ter spinal block (p=0.03 and p

Razvojem računala i numeričkih metoda pojavili su se uvjeti za numeričko modeliranje složenih strujanja kao što je strujanje krvi u arterijskom krvotoku. Cilj ovog rada je provesti numeričku simulaciju strujanja krvi kroz arterijsku premosnicu. U radu je definiran matematički model nestlačivog, izotermnog, laminarnog, 3D pulsirajućeg strujanja unutar krvne žile s krutom stijenkom. Izrađena su i analizirana dva geometrijski različita modela spajanja premosnice na zdravi dio krvne žile: spoj u obliku koljena i spoj u obliku račve. Pulsirajuće strujanje krvi ostvareno je propisivanjem vremenskog profila volumenskog protoka krvi na ulazu u domenu i ugradnjom Windkessel modela s 3 elementa kao rubnog uvjeta na izlazu iz domene. Uloga Windkessel modela je uzimanje u obzir podatljivosti krvne žile, perifernog otpora mikrocirkulacije i ulazne impedancije aortnog zaliska. Intenzitet oscilatornosti smičnih naprezanja uzet je u obzir umnoškom 𝑂𝑆𝐼 ∙ 𝜏𝑤, u kojem faktor 𝑂𝑆𝐼 iskazuje stupanj promjene smjera smičnog naprezanja, a 𝜏𝑤 predstavlja srednju vrijednost smičnog naprezanja na stijenci krvne žile. Iznos tog umnoška se koristi kao kriterij za procjenu uvjeta za stvaranje hiperplazije (zadebljanje stijenke krvne žile). Simulacija je provedena u programskom paketu OpenFOAM dok je analiza rezultata napravljena u programu ParaView i gnuplot. Rezultati simulacije pokazuju da su zbog nagle promjene smjera strujanja krvi i postojanja oštrih rubova vrijednosti smičnog naprezanja veće u slučaju spoja premosnice i krvne žile u obliku račve u usporedbi sa spojem u obliku koljena. Također su u slučaju spoja u obliku račve i vrijednosti umnoška 𝑂𝑆𝐼 ∙ 𝜏𝑤 nekoliko puta veće u području gdje se u stvarnim uvjetima očekuje nastanak hiperplazije. With the development of computers and numerical methods, the conditions for numerical modeling of complex flows such as blood flow in the arterial blood stream appeared. The aim of this work is to run a numerical simulation of blood flow through an arterial bypass. In this thesis is defined mathematical model of incompressible, isothermal, laminar, 3D pulsating flow inside a blood vessel with a rigid wall. Two geometrically different models of joining the bypass to a healthy part of the blood vessel were created and analyzed: a joint in the form of a knee and a joint in the form of a fork. The pulsatile blood flow was achieved by prescribing the time profile of the volume blood flow at the entrance to the domain and incorporating the Windkessel model with 3 elements as a boundary condition at the exit from the domain. The role of the Windkessel model is to consider the compliance of the blood vessel, the peripheral resistance of the microcirculation and the input impedance of the aortic valve. The intensity of oscillatory shear stress is considered by the product 𝑂𝑆𝐼 ∙ 𝜏𝑤, in which the OSI factor expresses the degree of change in the direction of wall shear stress, and 𝜏𝑤 represents the mean value of wall shear stress on the blood vessel wall. The amount of this product is used as a criterion for evaluating the conditions for the formation of hyperplasia (thickening of the blood vessel wall). The simulation was carried out in the OpenFOAM software package, while the results were analyzed in the ParaView and gnuplot. The simulation results show that due to the sudden change in blood flow direction and the existence of sharp edges, the wall shear stress values are higher in the case of the junction of the bypass and blood vessel in the form of a fork compared to the junction in the form of a knee. Also, in the case of joint in the form of a fork, values of the product 𝑂𝑆𝐼 ∙ 𝜏𝑤 are several times higher in the area where the occurrence of hyperplasia is expected in real conditions.

Coronary artery disease is a common and serious disease which is a consequence of plaque build-up in the coronary arteries. As a result, the artery cross-sectional area is reduced which restricts the blood flow. In this study, a numerical analysis of the blood flow through an idealised stenosed artery is presented. The effects of rheological models of blood on the flow characteristics is studied. Blood is modeled as a Newtonian, a generalized Newtonian and a viscoelastic fluid. For generalized Newtonian fluid modelling, the Carreau-Yasuda model is used. For viscoelastic fluid modelling, the simplified Phan-Thien-Tanner (sPTT) model is used. Flow is studied as steady and transient for three different stenosis geometries at Reynolds number values of 50 and 200. Results show that the Carreau-Yasuda model predicts the smallest boundary layer size and significantly lesser velocity magnitudes at the artery axis in comparison to the other models. The differences between model predictions are more noticeable when the stenosis is more severe and at higher velocities. Koronarna bolest srca je česta i ozbiljna bolest koja nastaje kao posljedica nakupljanja plaka na koronarnim arterijama. Uzrokuje smanjenje površine poprečnog presjeka arterije što otežava protok krvi. U ovom radu napravljena je numerička analiza strujanja krvi kroz idealiziranu stenotičnu arteriju. Analiziran je utjecaj reološkog modela krvi na strujne karakteristike. Krv je modelirana kao Newtonovski, generalizirani Newtonovski te viskoelastični fluid. Za modeliranje generaliziranog Newtonovskog fluida korišten je Carreau-Yasuda model, a za modeliranje viskoelastičnog fluida korišten je pojednostavljeni Phan-Thien–Tanner (sPTT) model. Proučavano je stacionarno i nestacionarno strujanje za tri različite geometrije stenoze pri vrijednostima Reynoldsovog broja 50 i 200. Rezultati pokazuju da Carreau-Yasuda model predviđa najmanji granični sloj i znatno manje magnitude brzina u osi arterije u usporedbi s ostalim modelima. Razlike između modela su primjetnije kada je stenoza veća te pri većim brzinama strujanja.

U ovom radu razvijen je novi tip srčane pumpe. Originalnost ovog koncepta je da se mehanička energija predaje fluidu trenjem, vrtnjom ravnih diskova koji nemaju lopatice. Primjenom analitičkih, numeričkih i eksperimentalnih metoda definiraju se parametri bezlopatične srčane pumpe (BSP). Iz Navier–Stokesovih jednadžbi je izveden matematički model strujanja te su određeni glavni geometrijski parametri BSP pumpe. Prilikom određivanja parametara uvedeni su kriteriji koje konstrukcija mora zadovoljiti. Prvi i najvažniji kriterij je da pumpa dobavlja krv unutar zadanih granica protoka i prirasta tlaka da bi se osigurala normalna cirkulacija krvi. Drugi vrlo važan kriterij je visoka hemokompatibilnost te minimalan negativan utjecaj BSP na krv (bez zona zastoja i recirkulacije strujanja, unutar prihvatljivog raspona tangencijalnog naprezanja). Također je bitno postići pumpu minimalnog volumena. Definiranje parametara konstrukcije centrifugalne bezlopatične srčane pumpe izvodi se u odnosu na referentnu srčanu pumpu HeartMate II (HM2), jer se kroz kliničku praksu pokazalo da uzrokuje najmanje komplikacija i da ima dobru hemokompatibilnost. Numeričkom simulacijom je, kroz postupna poboljšanja geometrije pumpe; određena konačna konstrukcija BSP pumpe bez recirkulacije i bez zona zastoja strujanja. Za radnu točku određenu sa tlakom Δp = 65 mmHg, protokom Q = 5 l/min i brojem okretaja ω = 6000 o/min određeni su parametri BSP konstrukcije: unutarnji radijus R1 = 12 mm, vanjski radijus R2 = 15 mm, udaljenost između diskova h = 1 mm, i broj diskova n = 6. Iznos tangencijalnog naprezanja u rotoru je u rasponu 46 – 108 Pa, a vrijeme prolaska fluida je 0,0194 sekundi. Uspoređujući HM2 i BSP pumpe po kriteriju hemokompatibilnosti pri tlaku Δp = 65 mmHg i kutnoj brzini ω = 6000 o/min. Protok kroz HM2 je Q = 5 l/min, dok je za pumpu BSP protok Q = 5,43 l/min. Pumpa HM2 ima tangencijalno naprezanje na zidu u rasponu od 0 do1025 Pa te skalarno smično naprezanje u rasponu od 0,0632 do 3302 Pa. Pumpa BSP ima tangencijalno naprezanje na zidu u rasponu od 0 do 308 Pa, a skalarno smično naprezanje u rasponu od 0 do 667 Pa. U novo razvijenoj BSP pumpi nema recirkulacijskih zona, ni zona zastoja što je sa stanovišta hemokompatibilnosti jako povoljno. Uz to BSP pumpa ima tangencijalno i skalarno smično naprezanje niže nego pumpa HM2 koju možemo smatrati vrlo dobrom izvedbom u smislu hemokompatibilnosti. The main function of the heart is to ensure continuous blood circulation to support normal body functions. Many life-threatening problems emerge if function of the heart is compromised. Therefore, if the heart is not able to ensure normal blood flow, it is extremely important that the blood flow is ensured by additional pumps called heart pumps. An artificial heart, i.e., a heart pump, is used to pump blood through the body when the heart itself is unable to do so. Cardiovascular diseases are the most common cause of death in the world. In the European Union countries, 42% of all deaths are due to cardiovascular diseases. Unfortunately, vascular system diseases are the main cause of death in Croatia. In 2016, the share of cardiovascular diseases in total mortality in Croatia was 45%, which means that almost every second person who died in Croatia, died of cardiovascular disease. A reasonable desire is to reduce these numbers, which in turn requires the development of heart pumps. Heart pumps provides the opportunity for people with heart disease to have significantly more time to receive a transplant (so-called bridge to transplantation). Also, heart pumps have the potential to permanently replace the patient heart when transplantation is not possible due to general health of the patient. In this research, a new type of heart pump is developed. The uniqueness of this pump concept is that the mechanical energy is transferred to the fluid by the rotation of flat discs without blades. Volumetric heart pumps with a diaphragm that provide pulsatile flow and heart pumps with blades that have continuous flow have already been developed. Heart pumps developed so far use shape, i.e., blades or diaphragm to transfer mechanical energy, while use of a bladeless pump as a heart pump is a complete novelty. Analytical, numerical, and experimental analyses are used to define the pump parameters that affect the heart pump hemocompatibility. The design parameters of a centrifugal bladeless heart pump are defined in relation to the reference heart pump. The HeartMate II Left Ventricular Assist Device from Thoratec Corporation (HM2) was selected as the reference heart pump. Through clinical practice, it was shown that HM2 causes the least complications and has good hemocompatibility. As part of this thesis, a bladeless heart pump (BSP) is designed. Hemocompatibility parameters of the BSP are equal to or better than HM2. Experimental analysis of the HM2 heart pump was performed in the interdisciplinary Laboratory for Artificial Cardiovascular Circulation, Faculty of Mechanical Engineering and Naval Architecture. For this purpose, an open-loop MOCK circulatory system was made for testing heart pumps. The MOCK circulatory system is made of Plexiglas and consists of a large tank, control valves, straight pipes of circular cross-section, a heart pump holder and a Venturimeter. In the experimental measurements, the prescribed standards for testing pumps defined by the ISO 9906: 2012 standard are met. The measured values are flow, pressure increase in the pump and suction pressure in the pump. All measuring chains were calibrated before the measurement and the measurement uncertainty of each individual measuring chain was assessed, according to ISO GUM standard. Measurements were performed with two different fluids: water and a solution of glycerol and water used as a substitute for blood. Based on the experimental results, the h – Q characteristic curves of the HM2 pump for both fluids are presented. The estimation of the total measurement uncertainty was performed based on the measurement uncertainty of each measuring chain and the deviation of the measured values of the h – Q curve from the regression curve. For the purposes of numerical calculation of the HM2 pump, it is necessary to know its geometry. Therefore, in the Laboratory for Precise Length Measurements, a cloud of points was obtained by precise CT scanning of the HM2 heart pump. The pump was scanned with a high-resolution detector (4000 x 3000 pixels), with a maximum CT scan resolution of 54 μm. After the described data collection, the 3D volume of the HM2 pump was reconstructed. Numerical analyses of HM2 was made in ANSYS Fluent 15.0. A 3D design of HM2, that was obtained by CT scanning, was used. The computer domain was divided into 6,4·106 control volumes, with the aim of achieving quality simulation. The mesh was refined in the boundary layer and near the joints and details. k – ω SST model was used to model turbulence. The rotation of the rotor was modeled using the Moving Reference Frame method. All numerical calculations were performed with a second order scheme of accuracy, until the result convergence and sufficient accuracy of the observed parameters was achieved. Shear stress magnitudes were calculated numerically. The Δp – Q characteristic curve for the HM2 pump was also calculated in the scope of the simulation. Quality of the numerical analysis settings was assessed by comparison of experimental and numerical results. Selected simulation settings were to be used for all further numerical calculations within this thesis. Different ranges of shear stress for which acceptable numerical hemocompatibility is achieved are reported in the literature. In this thesis, the narrowest range of 30 – 140 Pa was used for the reference shear stress range. Since these ranges are general, shear stress ranges for which hemocompatibility has been clinically confirmed have been taken from the numerical simulation of the reference heart pump HM2. The stated ranges of shear stresses need to be achieved in the numerical simulation of a bladeless centrifugal heart pump. This ensures the necessary condition of acceptable hemocompatibility for the new heart pump design. The flow inside the BSP can be divided into two parts, the flow inside the pump rotor and the flow in the connecting pipes. Energy transfer from the pump to the fluid is performed inside the rotor (active part of the pump). As the geometry of the BSP rotor is simple, it is possible to analyze the flow using Navier – Stokes equations. Although blood is a multiphase non-Newtonian fluid, the theoretical analysis introduced the assumption of blood as a single-phase Newtonian fluid with a density of 1050 kg/m3 and a dynamic viscosity coefficient of 0,0035 kg/(m s). Stationary flow was assumed, although there is a non-stationary velocity profile at the pump inlet resulting from active part of the heart. The relative Reynolds number is lower than the critical Reynolds number for the flow between the two plates, and laminar flow in the rotor was assumed. In addition to the above assumptions and limitations, a mathematical model of the flow in the BSP rotor was derived using the Navier – Stokes equations. The initial assumption was made for the rectified flow model. After that, the Navier – Stokes equation in cylindrical coordinates was solved. Algebraic expressions for the pressure field, velocity field, shear stress distribution on the disc, torque and force required for rotor rotation are derived. Furthermore, Δp – Q characteristic curve of the BSP pump was derived. Using the above terms and data obtained from the analysis of the HM2 pump, the main geometrical parameters of the BSP pump were determined. When determining the parameters, additional criteria were introduced that the structure must meet. The first and most important criterion is that the pump supplies blood within strict limits to ensure normal blood circulation throughout the body. The designed operating point Δp = 65 mmHg, Q = 5 l / min was selected for the construction of the BSP pump. Another very important criterion is high hemocompatibility and minimal negative impact of BSP on the blood (minimal thrombosis and hemolysis). The acceptable shear stress is within the range of 30 – 140 Pa. The third criterion is to achieve a minimum pump volume. The fourth criterion is the high efficiency of the pump due to the longer autonomy without charging the batteries. The first parameter selected in the theoretical analysis is the angular velocity. This parameter is independent, and all other parameters will depend on it. The designed operating point is defined at ω = 6000 rpm. From the condition that the shear stress is within the given limits, the inner radius of the disc is defined. Considering the criterion of the minimum pump volume, the outer radius of the disc and the number of discs are defined. Using the equations derived by solving the Navier – Stokes equations, the following were calculated: shear stress on the disc, pump power and torque required to rotate the rotor. Main parameters of the BSP pump were defined using theoretical analysis: pressure Δp = 65 mmHg and flow Q = 5.43 l/min at the designed operating point, angular speed ω = 6000 rpm, six discs 1 mm thick with 1 mm disc spacing, internal disc radius R1 = 12 mm, outer disc radius R2 = 15 mm. The range of shear stresses is from τϴz = 115 Pa at the bottom of the disc, to τϴz = 92 Pa at the top of the disc. The power of the pump is P = 1,324 W. The analytical equation Δp = Δp (Q) was derived from which the Δp – Q characteristic curve of the BSP pump was determined. Although all the main parameters required for the construction of a BSP pump have been derived by the theoretical analysis, it is impossible to design the geometry of the pump without numerical analysis. The ANSYS Fluent 15.0 program was used for flow analysis. The pump was analyzed as five identical computer domains. The domain consists of the space between two discs with the addition of a flow separator, and part of the domain of the inlet and outlet connecting pipes. In order to achieve a quality simulation, the domain was approximated with 1,1·105 control volumes. The mesh was refined in the boundary layer as well as near the junction of the flow separator and the connecting pipes. Turbulence was modeled with k – ε and k – ω SST turbulence models. In the thesis, gradual improvements of the pump shape are presented, up to the final fifth version of the pump shape, with which flow without stagnation and recirculation zones was achieved. The Δp – Q characteristic curve of the final version of the BSP pump design was calculated using numerical simulation. A comparison of the curves obtained by theoretical and numerical analysis shows that both curves are linear and coincide. The numerical Δp – Q characteristic curve was calculated considering the flow in the computation domain (with flow separator and connecting pipes), while the theoretical Δp – Q characteristic curve was calculated only for the rotor, i.e., the space between the disks. Therefore, resulting in incomplete coincidence between theoretical and numerical Δp – Q characteristic curves. Three parameters were used to assess the quality of the structure on hemocompatibility: wall shear stress (WSS), scalar shear stress (SSS) and residence time. The WSS in the rotor is in the range of 46 to 108 Pa, which is lower than the required value of the maximum WSS. The residence time of the fluid in the BSP pump is 0.0194 s. There is a small area (5% of the total volume) at the flow separator in which the values are higher than allowed (108 – 308 Pa). Exposure time in the area in question is short, in order of 5·10-4 s. According to the Hellums diagram for fluid residence time of 5·10-4 s, the allowable WSS is 700 Pa which is significantly higher than the calculated stress. During the numerical analysis, the SSS field was calculated, which determines the stress of the particles inside the fluid. 10% of the total volume was exposed to high linear stress in the fluid (SSS ˃ 100), 10% of the total volume was exposed to medium SSS (10

Sepsa je hemodinamski vrlo kompleksno stanje koje zahtjeva akutne dijagnostičke i terapijske postupke. Uporaba noradrenalina kao vazoaktivne potpore i glavnog supstrata za održavanje srednjeg arterijskog tlaka iznad 65 mmHg dobro je ustoličena klinička praksa, ali ne bez svojih limita. Uporaba sekundarnih vazoaktivnih lijekova poput vazopresina i sintetskog angiotenzina II, akutnije i vremenski definiranije liječenje sve više ulaze u jedinice intenzivne medicine. Praćenje progresije sepse, odnosno septičnog šoka, također biva unaprijeđeno, putem novijih modaliteta hemodinamskog monitoringa te novih point-of-care laboratorijskih nalaza koji točnije prate progresiju bolesti, na primjer promatranja dinamike renina. U ovom preglednom radu prikazane su novi modaliteti liječenja i personalizirani pristup pacijentu sa septičnim šokom te praćenja uspješnosti liječenja., Sepsis is a hemodynamically very complex condition that requires acute diagnostic and therapeutic procedures. The use of norepinephrine as vasoactive support and the main substrate for maintaining mean arterial pressure above 65 mmHg is a well-established clinical practice, but not without its limits. The use of secondary vasoactive drugs such as vasopressin and synthetic angiotensin II, and more acute and time-determining treatment are increasingly entering the intensive care units. Monitoring the progression of sepsis, or septic shock, is also being improved, through newer modalities of hemodynamic monitoring and new point-of-care laboratory findings that more closely monitor disease progression, for example by observing renin dynamics. In this review paper, new modalities of treatment and personalization of care for patients with septic shock and monitoring of treatment success are presented.

Razvojem računala i računalnih alata stvoreni su uvjeti za rješavanje fizikalnih problema računalnim simulacijama. Time se bitno skraćuje vrijeme projektiranja, smanjuje se trošak te se dobiva veća količina informacija za razliku od eksperimenata. U ovom radu potrebno je analizirati hemodinamiku koronarnih arterija za dva pacijenta. Hemodinamika, područje biomehanike, je grana fizike koja proučava strujanje krvi u kardiovaskularnom sustavu. Arterije su krvne žile koje se mogu prilagoditi i mijenjati u različitim hemodinamičkim uvjetima. Normalan tok u arterijama je laminaran, no u patološkim hemodinamičkim uvjetima arterije stvaraju abnormalan biološki odgovor. Ateroskleroza je bolest koja uzrokuje nastanak plaka na stijenki arterije čime se sužava poprečni presjek lumena zvan stenoza. Stenoza uzrokuje porast brzine strujanja krvi koje može dovesti do turbulentnog toka uz pojavu šuma, ali također može dovesti i do prekida strujanja te uzrokovati srčani udar. Istraživanja pokazuju da smanjena razina tangencijalnog naprezanja na stijenki koronarne arterije pogoduje razvoju plaka. U budućnosti će proučavanje arterijskog krvotoka dovesti do predviđanja pojedinačnih hemodinamičkih tokova kod pacijenata, razvoja dijagnostičkih alata za kvantificiranje bolesti i dizajna uređaja koji oponašaju ili mijenjaju protok krvi. Ovo je polje bogato izazovnim problemima u mehanici fluida koji uključuju trodimenzionalne, pulsirajuće tokove na rubu turbulencije. Zadatak ovog rada bio je provesti numeričku simulaciju strujanja krvi kroz koronarne arterije s ciljem određivanja raspodjele tangencijalnog naprezanja na stijenki. Geometrija je preuzeta u STL formatu, a iz nje je potrebno izraditi geometrijsku mrežu za proračun. Korišten je model nestlačivog nestacionarnog laminarnog strujanja. Numerička simulacija provedena je u softverskom paketu OpenFOAM, a rezultati su post-procesirani u ParaView-u. U analizi rezultata prikazano je polje brzine, polje tlaka te raspodjela tangencijalnog naprezanja po stijenki koronarnih arterija. The development of computers and computer tools has created the conditions for solving physical problems using computer simulations. This significantly shortens design time, reduces costs, and provides a greater amount of information compared to the experiment. In this thesis, it is necessary to analyze the hemodynamics of coronary arteries for two patients. Hemodynamics, the field of biomechanics, is a branch of physics that studies blood flow in the cardiovascular system. Arteries are blood vessels that can adapt and change with the varying hemodynamic conditions. Normal arterial flow is laminar, but under pathological hemodynamic conditions arteries create an abnormal biological response. Atherosclerosis is a disease that causes plaque to form on the artery wall, narrowing the cross section of the artery lumen called stenosis. Stenosis causes an increase in blood flow velocity and can lead to turbulent flow with the appearance of noise, but it can also lead to blockage of flow and cause heart attack. Studies show that reduced level of wall shear stress on the coronary artery wall favor plaque development. In the future, the study of arterial blood flow will lead to the prediction of individual hemodynamic flows in any patient, the development of diagnostic tools to quantify the disease and the design of devices that mimic or alter blood flow. This field is rich in challenging problems in fluid mechanics involving three-dimensional, pulsating flows at the edge of turbulence. The task of this thesis was to perform a numerical simulation of blood flow through the coronary arteries with aim to determine the distribution of wall shear stress on the wall. The geometry was downloaded in STL format and it is used to create a calculation grid. An incompressible transient laminar flow model was used. The numerical simulation was performed in the software package OpenFOAM, and the results were post-processed in ParaView. Analysis of the results shows the velocity field, the pressure field, and the distribution of wall shear stress along the coronary artery wall.

Razvojem računala i novih algoritama sve je učestalija primjena numeričkih metoda poput metode konačnih elemenata (MKE) i metode konačnih volumena (MKV) u području biomehanike i mehanike bioloških strujanja. Numeričke analize strujanja u krvožilnom sustavu uz medicinske pretrage daju više informacija i omogućuju precizniju dijagnostiku kardiovaskularnih bolesti. Ateroskleroza je bolest arterija koja uzrokuje formiranje plaka nakupljanjem masnoća na unutarnjoj stijenki. Kod ateroskleroze koronarnih arterija suženje poprečnog presjeka veće od 75% može dovesti do srčanog udara. Dijagnosticiranje i provođenje numeričke analize ne bi bilo moguće bez precizne rekonstrukcije geometrije koronarnih arterija oboljelog pacijenta. U ovom radu opisana je rekonstrukcija geometrije koronarnih arterija dvaju pacijenata na temelju CT koronarografskih snimaka. Iz rekonstruirane geometrije formirana je prostorna domena strujanja te je provedena njena diskretizacija i numerička analiza strujanja. Rekonstrukcija je provedena u programima 3DSlicer i Blender dok je proračunska mreža napravljena u programu cfMesh. Proračun je proveden pomoću programskog paketa OpenFOAM, a rezultati su obrađeni programom Paraview. With the development of computers and new algorithms, the application of numerical methods such as the finite element method (FEM) and the finite volume method (FEM) in the field of biomechanics and mechanics of biological flows is becoming more frequent. Numerical analyzes of the flow in the vascular system in addition to medical tests provide more information and allow a more accurate diagnosis of cardiovascular diseases. Atherosclerosis is a disease of the arteries that causes plaque to form by the accumulation of fat on the inner wall. In atherosclerosis of the coronary arteries, narrowing of the cross section by more than 75% can lead to a heart attack. Diagnosing and performing numerical analysis would not be possible without a precise reconstruction of the geometry of the coronary arteries of a diseased patient. This thesis describes the reconstruction of the coronary artery geometry of two patients from CT coronarographic images. Based on the reconstructed geometry, the spatial domain of the flow is defined and discretised and numerical analysis of the flow was performed. The reconstruction was carried out in 3DSlicer and Blender while mesh is made in cfMesh. The calculation was performed using the OpenFOAM software package, and the results were processed with the Paraview program.

Out-of-hospital-cardiac-arrest (OHCA) is a sudden cardiovascular event that constitutes a major public health problem and is one of the leading causes of death in the world. The survival rate from OHCA decreases with time, therefore its early recognition and treatment is key. Defibrillation and cardiopulmonary resuscitation maneuver are the fundamental OHCA therapies. Electrocardiogram (EKG) is a low cost noninvasive technique used to monitor the electrical status of the heart. However, in many OHCA cases the EKG shows a close to normal electrical activity of the heart when actually the hemodynamic activity of the heart (blood flow and pressure) is not effective. Consequently, a noninvasive, inexpensive and reliable technique that allows real-time monitoring of the hemodynamic status of the pa- tient would be of great value. However, currently no such technique exists for out-of-hospital situations and it is only available in hospitals. Cardiac output (CO) and stroke volume index (SVI) are the main indica- tors of hemodynamic status. The objective of this master thesis has been to develop and imple- ment the tools to help establish correlations between CO and SVI values measured by well-established in-hospital technologies (invasive blood pressure and doppler echocardiography), and the measures taken from novel noninvasive signals such as ballistocardiography (BCG) sensors that could be easily used in OHCA. The first step was to collect data from a cohort of healthy subjects with both types of technologies. In May 2021 started the collection of real OHCA cases. To accomplish the main objective several interme- diate objectives have been defined and achieved; first, the creation of a multisource, standardized and common open format database using raw data from the different proprietary measurement devices. For this purpose, existing data converters have been applied and custom data converters have also been developed. The data have been preliminar- ily pseudo-synchronized with a custom-made algorithm based on the temporal annotations of the physicians. Two graphical interfaces have been created, one for each site (out- of- and in-hospital) that have collected the measurements for the database. The graphical interfaces are user-friendly, flexible, and func- tional to enable visualization, annotation and time alignment fine tun- ing of the multisource standardized database. They also integrate al- gorithms to help the analysis of the data and find possible hidden cor- relations between signals. The creation of these two interfaces has led to two outcomes: on the one hand, the extraction of analysis windows together with the physicians of the Oslo University Hospital. On the other hand, the creation of a generalist graphical interface develop- ment method. Thanks to this method, a third graphical interface has been built to analyze the extracted windows. This also integrates a fifth algorithm for data processing. In conclusion, a scalable platform has been created both in num- ber of patients and mesurement devices, consisting of a multisource, standardized, common open format database and three graphical in- terfaces for its visualization, annotation and processing. This platform sets the framework to help the future identification of the correlation between the different technologies that will save lives thanks to real- time hemodynamic monitoring in emergency medical services-treated OHCA cases. Ospitalez kanpoko bihotz geldialdia (OKBG) ustekabeko gertakari kardiobaskular bat da, osasun publikoko arazo garrantzitsua dena, munduko heriotza-kausa nagusietako bat izanez. OKBGaren biziraupen- tasa murriztu egiten da denborarekin, eta, beraz, haren antzemate eta tratamendu goiztiarrak funtsezkoak dira. Bi dira OKBGaren oinar- rizko terapiak: desfibrilazio eta bihotz-biriketako berpizte (BBB) goiz- tiarrak. Elektrokardiograma (EKG) kostu txikiko teknika ez-inbaditzailea da, bihotzaren egoera elektrikoa monitorizatzeko erabiltzen dena. Hala ere, OKBGko kasu askotan, EKGak bihotzaren jarduera elektriko sasi- normala erakusten du, nahiz eta bihotzaren jarduera hemodinamikoa (odol-fluxua eta presioa) eraginkorra ez izan. Beraz, oso baliagarria litzateke teknika ez-inbaditzailea, merkea eta fidagarria izatea pazientearen egoera hemodinamikoa denbora errealean monitorizatzeko. Zoritxarrez, gaur egun ez dago horre- lako teknikarik ospitalez kanpoko egoeretarako eta ospitaleetan baino ezin da erabili. Egoera hemodinamikoaren adierazle nagusiak bi dira: bihotz-gastua (BG) eta bolumen sistolikoaren indizea (BSI). Master amaierako lan honen helburua dagoeneko ondo ezarrita dauden ospitalez barruko teknologiek (odol-presio inbaditzailea eta doppler ekokardiografia), eta OKBGan erraz erabil daitezkeen diren seinale berri ez inbasiboak, hala nola, balistokardiografia (BCG) sentsoreak neurtutako BG eta BSI balioen arteko korrelazioak topatzen lagunduko duten tresnak garatzea eta inplementatzea izan da. Lehenengo urratsa bi teknologia motekin datuak biltzea izan zen, subjektu osasuntsuen talde batetik abiatuta. 2021eko maiatzean hasi ziren benetako OKBG kasuetako datuak biltzen. Helburu nagusia lortzeko, tarteko helburu batzuk definitu eta lortu dira; lehenik eta be- hin, iturri anitzetako datu-base estandarizatua eta formatu ireki ko- munekoa sortu da. Horretarako, neurketa-ekipoek jasotako datu gor- dinak (formatu jabeduna zeukatenak) erabili dira. Hori lortzeko, da- goeneko existitzen ziren datu-bihurgailuak aplikatu dira, baita garatu- tako datu-bihurgailu propioak ere. Datuak aldez aurretik sinkronizatu dira algoritmo propio baten bidez. Algoritmo horrek medikuen denbora- oharrak hartzen ditu oinarritzat. Bi interfaze grafiko sortu dira, datu-baserako neurketak hartu di- tuzten teknologien aplikazio-esparru bakoitzeko bat (ospitalez kan- poko eta barrukoa). Interfaze grafikoak erabiltzeko errazak dira, mal- guak eta funtzionalak. Haiei esker datu-basea bistaratzen, anotatzen eta denbora-lerrokatzea doitzen da. Interfazeek datuak aztertzen la- guntzeko eta seinaleen arteko ezkutuko korrelazioak aurkitzeko algo- ritmoak ere badituzte. Bi interfaze horiek sortzeak bi emaitza ekarri ditu: batetik, analisi-leihoak atera dira Osloko Unibertsitate Ospitaleko medikuekin batera. Bestetik, interfaze grafikoak garatzeko metodo orokor bat sortu da. Metodo horri esker, hirugarren interfaze grafiko bat eraiki da ateratako leihoak aztertzeko. Interfaze honek bosgarren algo- ritmo bat ere integratzen du datuak prozesatzeko. Ondorioz, plataforma eskalagarri bat sortu da, bai paziente zein neurketa-ekipoen kopuruari dagokienez. Plataforma hori osatzen dute iturri anitzetako datu-base estandarizatu eta formatu ireki komuneko bat, eta hiru interfaze grafiko, datuak ikusi, anotatu eta prozesatzeko. La parada cardiorespiratoria extrahospitalaria (PCREH) es un evento cardiovascular súbito que constituye un importante problema de salud pública y es una de las principales causas de muerte en el mundo. La tasa de supervivencia a una PCREH disminuye con el tiempo, por lo que su reconocimiento y tratamiento tempranos son clave. La desfibrilación y la maniobra de reanimación cardiopulmonar son las terapias funda- mentales de la PCREH. El electrocardiograma (EKG) es una técnica no invasiva de bajo coste que se utiliza para monitorizar el estado eléctrico del corazón. Sin embargo, en muchos casos de PCREH el EKG mues- tra una actividad eléctrica del corazón relativamente normal cuando realmente la actividad hemodinámica del corazón (flujo y presión san- guínea) no es efectiva. Por lo tanto, resultaría muy útil contar con una técnica no invasiva, barata y fiable que permitiera monitorizar en tiempo real el estado hemodinámico del paciente. Sin embargo, actualmente no existe ninguna técnica de este tipo para situaciones extrahospitalarias, tan sólo está disponible en los hospitales. El gasto cardíaco (GC) y el índice de volumen sistólico (IVS) son los principales indicadores del estado hemodinámico. El objetivo de este trabajo de fin de máster ha sido desarrollar e implementar las herramientas que ayuden a establecer correlaciones entre los valores de GC y IVS medidos por tecnologías intrahospitalarias ya consolidadas (presión arterial invasiva y ecocardiografía doppler), y las medidas tomadas a partir de novedosas señales no invasivas como los sensores de balistocardiografía (BCG) que podrían ser fácilmente utilizados en la PCREH. El primer paso fue recopilar datos de una cohorte de sujetos sanos con ambos tipos de tecnologías. En mayo de 2021 se inició la recogida de casos reales de PCREH. Para lograr el objetivo principal se han definido y alcanzado varios objetivos intermedios; en primer lugar, la creación de una base de datos multifuente, estandarizada y con un for- mato abierto común, utilizando los datos sin procesar en formato propi- etario de los diferentes equipos de medida. Para ello, se han aplicado conversores de datos existentes y también se han desarrollado conver- sores de datos propios. Los datos se han sincronizado preliminarmente con un algoritmo propio que toma como base las anotaciones tempo- rales de los médicos. Se han creado dos interfaces gráficas, una por cada lugar de apli- cación (extra e intrahospitalaria) de las tecnologías que han captado las medidas para la base de datos. Las interfaces gráficas son fáciles de usar, flexibles y funcionales para permitir la visualización, la anotación y el ajuste de la alineación temporal de la base de datos. También in- tegran algoritmos para ayudar al análisis de los datos y encontrar posi- bles correlaciones ocultas entre las señales. La creación de estas dos interfaces ha dado lugar a dos resultados: por un lado, la extracción de ventanas de análisis junto con los médicos del Hospital Universitario de Oslo. Por otro, la creación de un método general de desarrollo de in- terfaces gráficas. Gracias a este método, se ha construido una tercera interfaz gráfica para analizar las ventanas extraídas. Ésta también inte- gra un quinto algoritmo para el procesamiento de datos. En conclusión, se ha creado una plataforma escalable tanto en número de pacientes como de dispositivos de medición, que consiste en una base de datos multifuente, estandarizada y de formato abierto común y tres interfaces gráficas para su visualización, anotación y procesamiento. Esta plataforma establece el marco para ayudar a la fu- tura identificación de la correlación entre las diferentes tecnologías que salvarán vidas gracias a la monitorización hemodinámica en tiempo real en las PCREH tratados por los equipos médicos de emergencia.

The study aimed to determine if the non-dipping pattern of blood pressure (BP) influences preterm delivery in gestational hypertension (GH), but also maternal clinical findings and birth weight. Sixty women with GH, i.e. 30 women with a dipping BP profile (control group) and 30 non-dippers (study group), were included in the study. Echocardiography was performed in all subjects, as well as ambulatory blood pressure monitoring (ABPM) during third trimester. ABPM was repeated 6-8 weeks after delivery. Thirteen women with preterm delivery were classified as non-dippers and only four as dippers (p=0.01). The average and peak systolic and diastolic night-time BP had negative linear correlation with birth weight (p, Cilj ovoga istraživanja bio je utvrditi povezanost non-dipping profila krvnog tlaka (KT) s prijevremenim porođajem, porođajnom težinom novorođenčeta te kliničkim i ehokardiografskim parametrima kod žena s gestacijskom hipertenzijom (GH). Istraživanje je obuhvatilo 60 žena s GH, 30 s dipping profilom KT (kontrolna skupina) i 30 non-dippera (ispitna skupina). Sve žene podvrgnute su kompletnoj ehokardiografiji i 24-satnom ambulantnom praćenju krvnog tlaka (ambulatory blood pressure monitoring, ABPM) tijekom trećeg trimestra, a ABPM je ponovljen 6-8 tjedana nakon porođaja. Ukupno 17 žena imalo je prijevremeni porođaj. Trinaest žena s prijevremenim porođajem imalo je non-dipping profil KT, dok su samo četiri žene imale dipping profil KT (0,01). Prosječni i maksimalni sistolički i dijastolički noćni KT imali su negativnu linearnu korelaciju s porođajnom težinom (p

Cilj disertacije: Svrha ovog istraživanja bila je ispitati mogu li se vaskularne promjene u perifernoj i cerebralnoj cirkulaciji izazvane ronjenjem spriječiti oralnim dodavanjem antioksidansa. Nadalje, ispitali smo hipotezu da će promijenjeni hemodinamski parametri nakon zarona SCUBA dovesti do promjena cerebralnog protoka krvi u mirovanju i tijekom vježbanja. Materijali i metode: Ovo kliničko istraživanje provedeno je u Zavodu za integrativnu fiziologiju Medicinskog fakulteta Sveučilišta u Splitu. U prvoj fazi istraživanja, 14 ronioca izvelo je jedno podvodno ronjenje na 18-metarskoj morskoj dubini tijekom 47 minuta. 12 ronioca sudjelovalo je u naknadnom istraživanju koja je uključivalo udisanje 60% kisika pod atmosferskim tlakom tijekom 47 minuta. Prije oba istraživanja sudionici su 6 dana unosili vitamin C (2 g/dan) ili placebo. Nakon 2 tjedna ispiranja, studija je ponovljena s različitim stanjima. Vazodilatacija ovisna o endotelu brahijalne arterije procijenjena je prije i nakon intervencije pomoću tehnike dilatacije posredovane protokom (FMD). U drugoj fazi istraživanja, 16 ronioca izvršilo je jedan zaron na na 18-metarskoj morskoj dubini tijekom 47 minuta. Nadzorna laboratorijska mjerenja provedena su tjedan dana kasnije. Transkranijski Doppler ultrazvuk korišten je za mjerenje intrakranijskih brzina krvi. Rezultati: FMD je smanjen za ~32,8% i ∼21,2% nakon zarona u ispitivanju s placebom i vitaminom C, a posthiperoksično stanje u ispitivanju s placebom za ∼28,2% (P0,05). Povišenje brzine intrakranijalne krvi 30 minuta nakon izranjanja na površinu od ronjenja smanjeno je u studiji s vitaminom C u usporedbi s ispitivanjem placeba (P0,05). Profilaktičko uzimanje vitamina C učinkovito je poništilo perifernu vaskularnu disfunkciju nakon izlaganja 60% O2, ali nije ukinulo smanjenje FMD-a nakon post-zarona. Prolazna povišenja intrakranijalnih brzina nakon zarona smanjena su vitaminom C. Nakon zarona u mirovanju, srednja brzina cerebralne arterije (MCAv) povišena je 15 i 30 minuta nakon izranjanja (za 3,3±5,8, odnosno 4,0±6,9 cm/s; P 0.05). Elevations in intracranial blood velocities 30 min after surfacing from diving were reduced in the vitamin C study compared with the placebo trial (P0.05). Prophylactic ingestion of vitamin C effectively abrogated peripheral vascular dysfunction following exposure to 60% O2 but did not abolish the postdive decrease in FMD. Transient elevations of intracranial velocities postdive were reduced by vitamin C. Following the dive at rest, middle cerebral artery velocity (MCAv) was elevated 15 and 30 min after surfacing (by 3.3±5.8 and 4.0±6.9 cm/s, respectively; P

Introduction: Type 2 Diabetes Mellitus (T2DM) is a prevalent cause of morbidity and mortality, particularly due to chronic complications development, most commonly cardiovascular diseases. Among markers for assessment of clinical and subclinical signs of cardiovascular disease, the presence of arteriosclerosis, and stiffening of arterial walls as indicated by the arterial stiffness, was proven to be an important predictor of adverse cardiovascular events. Carotid-femoral pulse wave velocity (PWV) is considered as gold standard for arterial stiffness measurement. On the other side, moderate red wine (RW) consumption was shown to have cardioprotective effects by multiple epidemiologic and experimental studies. Objective: The objective of this study was to examine the effects of moderate daily red wine intake on arterial stiffness and hemodynamic parameters in participants with well controlled T2DM. Subjects and Methods: 18 well controlled-T2DM participants (taking metformin alone or with oral antidiabetic drugs as chronic therapy) were included in the cross-over interventional study during five weeks; the first two weeks being the drive-in period with no alcohol consumption (control), followed by three weeks of moderate, 300 ml per day, consumption of red wine Plavac mali with meals (intervention). At the end of each experimental period we assessed anthropometric data (body mass index), performed biochemical blood analysis (fasting plasma glucose, and HbA1c), while oscillometric and tonometric measurements of arterial stiffness (pulse wave velocity, peripheral and central augmentation indices) and hemodynamic parameters (heart rate, peripheral and central systolic, diastolic and pulse pressure) were performed by Arteriograph and SphygmoCor devices, respectively. Results: Moderate RW consumption in well-controlled T2DM participants induced significant decrease of PWV (7.42±1.44 m/s for control, no alcohol period vs. 6.98±1.44 m/s for intervention, wine consumption period, P=0.013) and peripheral arterial diastolic pressure (79.72±11.47 mmHg in control, no alcohol period vs. 76.39±11.15 mmHg for intervention, wine consumption period, P=0.034), while other arterial stiffness and hemodynamic parameters were not significantly changed although showing a trend of decline. Conclusion: In a cohort of subjects with well controlled T2DM, in whom clinical symptoms of cardiovascular disease were not yet expressed, there was a decrease in PWV. This indicates an improvement in arterial stiffness even after moderate consumption of red wine of relatively short duration., Uvod: Šećerna bolest tipa 2 važan je uzrok obolijevanja i smrtnosti posebice zbog razvoja kroničnih komplikacija od kojih su najčešće kardiovaskularne bolesti. Među markerima za procjenu kliničkih i subkliničkih znakova kardiovaskularnih bolesti, smanjenje arterijske elastičnosti, arterioskleroza, i pojava ukrućivanja stijenke arterija, engl. arterial stiffness, pokazalo se pouzdanim prediktorom kardiovaskularnog rizika. Karotidno-femoralna brzina pulsnog vala smatra se zlatnim standardom procjene arterijske elastičnosti/krutosti. S druge strane, kardioprotektivni učinci umjerene konzumacije crnog vina pokazani su u epidemiološkim i eksperimentalnim istraživanjima. Cilj: Istražiti učinke umjerene konzumacije crnog vina na hemodinamske parametre i parametre arterijske elastičnosti u ispitanika oboljelih od šećerne bolesti tipa 2, kod kojih je bolest dobro nadzirana. Ispitanici i metode: U ukriženo intervencijsko istraživanje uključeno je 18 ispitanika s dobro nadziranom šećernom bolesti tipa 2 (uz kroničnu terapiju metforminom) tijekom pet tjedana: dva tjedna bez konzumacije ikakvih alkoholnih pića, drive-in faza pokusa (kontrolna), nakon kojega je slijedilo tri tjedna umjerene konzumacije crnog vina sorte Plavac mali od 300 ml dnevno uz obrok (intervencija). Na kraju svake faze pokusa ispitanicima su izmjereni antropometrijski parametri (indeks tjelesne mase), učinjena biokemijska analiza krvi (plazmatska koncentracija glukoze natašte i koncentracija HbA1c), a hemodinamski parametri (srčana frekvencija, periferni i središnji sistolički, dijastolički i pulsni tlak) i parametri arterijske elastičnosti (brzina pulsnog vala, periferni i središnji augmentacijski indeksi) određeni su oscilometrijskom (Arteriograph) i tonometrijskom (SphygmoCor) metodom. Rezultati: Nakon umjerene konzumacije vina došlo je do smanjenja brzine pulsnog vala (7,42±1,44 m/s u kontrolnoj fazi pokusa bez konzumacije alkoholnih pića vs. 6,98±1,44 m/s nakon intervencije, P=0,013) i perifernog dijastoličkog tlaka (79,72±11,47 mmHg u kontrolnoj fazi pokusa bez konzumacije alkoholnih pića vs. 76,39±11,15 mmHg nakon intervencije, P=0,034), dok su promjene ostalih hemodinamskih parametara i parametara arterijske elastičnosti bili statistički neznačajne, unatoč ostvarenom trendu smanjena. Zaključci: U kohorti ispitanika s dobro nadziranom šećernom bolesti tipa 2, kod kojih još nisu izraženi klinički simptomi kardiovaskularne bolesti, došlo je do smanjenja brzine pulsnog vala. To ukazuje na poboljšanje arterijske elastičnosti čak i nakon umjerene konzumacije crnog vina relativno kratkog trajanja.

Izhodišče Mikrohemodinamsko dogajanje in regionalna dostava kisika sta v anesteziologiji pomembna zaradi povezave med moteno mikrocirkulatorno funkcijo in slabšim perioperativnim izhodom. Kljub manj boleči laparoskopski kirurški tehniki v primerjavi s klasično “odprto” kirurgijo pa bolnice po laparoskopskih ginekoloških operacijah občutijo hudo bolečino v 40% do 65% primerov. Dodatek intratekalne anelgezije k splošni anesteziji bi teoretično lahko izboljšal mikrocirkulacijo in perioperativno zdravljenje bolečine ter zmanjšal stresni odgovor. Metode Bolnice (n=102), ki so imele načrtovano laparoskopsko ginekološko operacijo, smo naključno razvrstili v tri skupine. Prejele so kombinacijo splošne anestezije z nizkim odmerkom intratekalne analgezije (NOIA: 7,5 mg levobupivakaina in 2,5 μg sufentanila) ali zelo nizkim odmerkom intratekalne analgezije (ZNOIA: 3,75 mg levobupivakaina in 2,5 μg sufentanila) ali zgolj splošno anestezijo (kontrolna skupina). Uporabili smo 3 minutni zažemni test in s spektroskopijo blizu infrardečega spektra izmerili tkivno oksigenacijo in opredelili mikrocirkulatorno funkcijo v m. brachioradialis in m. triceps surae v treh časovnih točkah: pred uvodom v splošno anestezijo, 5 minut po trahealni intubaciji in 15 minut po začetku pnevmoperitoneja. Primarni mikrohemodinamski izidi so bili: (1) primerjava spektroskopsko dobljenih mikrohemodinamskih parametrov med skupinami (2) primerjava mikrovaskularnih trendov v mišicah nog s tistimi v mičicah rok znotraj skupin in (3) korelacija krvnega tlaka s hitrostjo povratka tkivne oksigenacije po zažemnem testu. Trije primarni cilji s področja lajšanja bolečine so bili: (1) poraba sufentanila med operativnim posegom (2) poraba piritramida za zdravljenje pooperativne bolečine in (3) ocena bolečine z 11 točkovno številčno lestvico (od 0 do 10). Za oceno zgodnjega stresnega odgovora smo določili nivo kortizola in glukoze v serumu pred in med operacijo. Rezultati Med tremi skupinami ni bilo razlik v mikrohemodinamskih parametrih na podlahti. Na merilnem mestu na nogi so imele bolnice v skupinah z dodatkom intratekalne analgezije že pred uvodom v anestezijo počasnejšo hitrost tkivne reoksigenacije po zažemnem testu (NOIA 34 ±16 %/min, p=0,002 ZNOIA 36 ±13 %/min, p=0,006) v primerjavi s kontrolno skupino (52 ±27 %/min). Med splošno anestezijo smo opazili poslabšanje mikrocirkulatorne funkcije v vseh skupinah in razlik med njimi več ni bilo zaznati, med laparoskopijo pa smo zaznali pomembno zmanjšanje hitrosti tkivne reoksigenacije po zažemnem testu v skupini z NOIA (14 ±11 %/min) v primerjavi z ZNOIA (22 ±11 %/min p=0,023) in kontrolno skupino (24 ±17 %/min p=0,040). Poraba sufentanila (mediana [interkvartilni razpon]) je bila 2,9 (0-4) μg/h v skupini z NOIA, 4,7 (3,2-9,2) μg/h v skupini z ZNOIA in 16 (11-23) μg/h v kontrolni skupini (p

Osmogodišnji dječak naručen je na elektivnu tonzilektomiju zbog ponavljanih upala srednjeg uha uzrokovanih hipertrofijom adenoida. Pacijent je imao otvoreni, tj. perzistentni arterijski duktus (engl. Persistent ductus arteriosus – PDA), čestu prirođenu srčanu grešku s očuvanom komunikacijom između aorte i plućne arterije. Kod pacijenta je postojao samo hemodinamski neznatan lijevo-desni pretok. Trenutačne smjernice za anesteziju pacijenata s lijevo-desnim pretokom uključuju: 1. održavanje ili smanjenje sustavnoga vaskularnog otpora (SVR) kao hemodinamski cilj ; 2. izbjegavanje smanjenja plućnoga vaskularnog otpora (PVR) ; 3.izbjegavanje hiperoksije i hipokarbije. Predoperacijska obrada uključivala je suradnju s pedijatrijskim kardiologom koji je napravio procjenu pacijentova srčanog statusa, uključujući ultrazvuk srca i elektrokardiogram (EKG). Tijek anestezije protekao je bez neželjenih događaja. Nakon reverzije neuromuskularne blokade i ekstubacije pacijent je budan, hemodinamski stabilan i zadovoljavajućega respiratornog stanja prebačen u sobu za oporavak poslije anestezije. Preoksigenacija 100%-tnim kisikom prijeporna je u ovakvih pacijenata. Detaljna predoperacijska procjena srčanog statusa i izbjegavanje povećanja protoka kroz otvorenu komunikaciju ključni su za dobar ishod u pacijenata s PDA-om.

Osmogodišnji dječak naručen je na elektivnu tonzilektomiju zbog ponavljanih upala srednjeg uha uzrokovanih hipertrofijom adenoida. Pacijent je imao otvoreni, tj. perzistentni arterijski duktus (engl. Persistent ductus arteriosus – PDA), čestu prirođenu srčanu grešku s očuvanom komunikacijom između aorte i plućne arterije. Kod pacijenta je postojao samo hemodinamski neznatan lijevo-desni pretok. Trenutačne smjernice za anesteziju pacijenata s lijevo-desnim pretokom uključuju: 1. održavanje ili smanjenje sustavnoga vaskularnog otpora (SVR) kao hemodinamski cilj; 2. izbjegavanje smanjenja plućnoga vaskularnog otpora (PVR); 3.izbjegavanje hiperoksije i hipokarbije. Predoperacijska obrada uključivala je suradnju s pedijatrijskim kardiologom koji je napravio procjenu pacijentova srčanog statusa, uključujući ultrazvuk srca i elektrokardiogram (EKG). Tijek anestezije protekao je bez neželjenih događaja. Nakon reverzije neuromuskularne blokade i ekstubacije pacijent je budan, hemodinamski stabilan i zadovoljavajućega respiratornog stanja prebačen u sobu za oporavak poslije anestezije. Preoksigenacija 100%-tnim kisikom prijeporna je u ovakvih pacijenata. Detaljna predoperacijska procjena srčanog statusa i izbjegavanje povećanja protoka kroz otvorenu komunikaciju ključni su za dobar ishod u pacijenata s PDA-om., The 8-year-old boy was scheduled for an elective tonsillectomy because of a recurring middle ear infection, caused by adenoid hypertrophy. The patient had a patent ductus arteriosus (PDA), a common congenital heart defect with a persistent communication between the aorta and the pulmonary artery. In this patient, there was only a haemodynamically insignificant left-to-right shunt. Current guidelines for anaesthetic management of patients with left-to-right shunt include: 1. Maintenance or decrease of systemic vascular resistance (SVR) as a haemodynamic goal; 2. Avoiding decreases in pulmonary vascular resistance (PVR); 3. Avoiding hyperoxia and hypocarbia. The preoperative assessment included collaboration with paediatric cardiologist who reevaluated the patient’s cardiac status, including a heart ultrasound and an ECG cardiography. The course of anaesthesia was uneventful. After neuromuscular blockade reversion and extubation, the patient was transferred to the post-anesthesia care unit (PACU) awake, haemodynamically stable and with satisfactory respiratory status. The preoxygenation with 100% oxygen is a source of controversy. In a patient with PDA, a thorough preoperative evaluation of cardiac status and avoidance of worsening left-to-right shunt are essential for good outcome.

Uvod-Kardiovaskularne bolesti su vodeći uzrok smrti i radne nesposobnosti u Evropi, predstavljajuveliko socijalno i ekonomsko opterećenje. Bolesti periferne arterijske cirkulacije se mogu podeliti udve celine i to na okluzivne i neokluzivne bolesti, odnosno funkcionalne smetnje. Učestalostarterijske bolesti donjih ekstremiteta snažno je povezana sa godinama starosti. Faktori rizika zaperifernu arterijsku bolest su slični onima koji su važni u etiologiji koronarne arterijske bolesti:gojaznost, pušenje, dislipidemija, šećerna bolest, hipertenzija. Najtipičnija prezentacija perifernearterijske bolesti je intermitentna klaudikacija koja se karakteriše bolom u listovima koji sepojačava pri hodanju; bol obično nestaje u miru. Svi gojazni pacijenti sa perifernom arterijskombolešću donjih ekstremiteta imaju povećan rizik od budućih kardiovaskularnih događaja, te je kodnjih obavezna opšta sekundarna prevencija u cilju poboljšanja prognoze. Fizičko vežbanjepredstavlja metodu izbora kod obolelih od periferne arterijske bolesti donjih ekstremiteta.Cilj istraživanja: Uporediti efekte programirane fizičke aktivnosti i medikamentozne terapije nahemodinamiku i riziko faktore za kardiovaskularna obolenja kod gojaznih osoba obolelih odperiferne arterijske bolesti donjih ekstremiteta.Ispitanici i metode istraživanja: Obavila se retrospektivna-prospektivna, klinički deskriptivna,kontrolisana studija, na ispitanicima Javne Ustanove Domovi Zdravlja Kantona Sarajevo -Specijalističko konsultativna delatnost. OJ Specijalističko konsultativna delatnost predstavljasekundarni vanbolnički nivo zdravstvene zaštite. Ovom studijom se evaluirao period od 20 nedelja(140 dana). U studiju je uključeno 75 ispitanika. Na početku istraživanja, na osnovu nalaza kolorDoppler sonografije pedalnih arterija, nalaza ejekcione frakcije leve komore, spirometrijskognalaza, vrednosti pulsnog aortalnog pritiska te utvrđivanja preterane uhranjosti – gojaznostiispitanici su uključeni u istraživanje. Osim ultrazvučnog nalaza i nalaza spirometrije, pacijenti sudali i iscrpnu anamnezu o prethodnim obolenjima. Uradilo se merenje indeksa telesne težine, obimstruka i klaudikacione distance. Lipidogram kao i jutarnji šećer su bili urađeni za svakog pacijenta.Pacijentima je prepisana ili produžena medikamentozna terapija, te data detaljna upustva zasvakodnevni program vazoaktivne šetnje.Rezultati istraživanja: Na početku istraživanja prosečna vrednost obima struka ispitanika jeiznosila 87,94±3,07cm, nakon dve sedmice prosečan obim struka je iznosio 87,10±2,0 cm, a nakraju istraživanja 84,96±1,98cm. Na početku istraživanja ispitanici ispitivane grupe su imali indekstelesne mase od 28,93±2,10 kg/m2. Nakon dve sedmice istraživanja i provedene terapije indekstelesne mase se smanjio i iznosio 28,36±1,99 kg/m2, da bi na kraju istraživanja prosečna vrednostindeksa telesne mase u ispitivanoj grupi iznosio 27,26±1,87 kg/m2. Prosečna vrednost glukoze ukrvi na početku istraživanja je iznosila 5,77±0,96 mmol/L, tokom istraživanja ta vrednost je bila5,42±0,88 mmol/L, a na kraju istraživanja 5,30±0,92 mmol/L. Postprandijalna vrednost glukoze ukrvi je na početku istraživanja iznosila7,48±0,85 mmol/L, tokom istraživanja ta vrednost je bila6,82±0,62 mmol/L, a na kraju istraživanja 6,44±0,64 mmol/L. Na početku istraživanja vrednostHbA1c je iznosila 5,52±0,91%, tokom istraživanja 5,32±0,97%, a na kraju istraživanja5,09±0,73%.Prosečna vrednost CRP-a na početku istraživanja je iznosila 3,77±1,12mg/L, tokomistraživanja vrednost je iznosila 3,66±1,36mg/L, da bi na kraju istraživanja ta vrednost iznosila3,61±1,21mg/L. Uparenim t-testom nije ustanovljeno statistički značajno smanjenje ili povečanjeCRP-a tokom istraživanja. Prosečna vrednost holestarola u krvi ispitanika na početku istraživanjaje bila iznad referentnih vrednosti i iznosila 6,58±0,90 mmol/L. Nakon dve sedmice istraživanja iprovedene terapije vrednost je iznosila 4,96±0,46 mmol/L, da bi na kraju istraživanja vrednostiznosila 4,15±0,54 mmol/L. Prosečne vrednosti triglicerida na početku i tokom istraživanja su bilepovišene, da bi na kraju istraživanja bile u okvirima referentnih vrednosti. Razlika izmeđuVIvrednosti leptina kod muškaraca na početku i kraju istraživanja je iznosila 2,66±1,52 ng/ml(t=3,024; p=0,094) dok kod ispitanica ženskog pola nije došlo do statistički značajne razlike.Prosečne vrednosti viskoznosti plazme su na početku i tokom istraživanja bile iznad referentnihvrednosti da bi na kraju istraživanja ta vrednost bila u granicama fizioloških vrednosti. Prosečnevrednosti PSV na početku i tokom istraživanja su bile u granicama patoloških vrednosti da bi nakraju istraživanja vrednost bila u granicma fizioloških vrednosti. Na početku istraživanja prosečnavrednost PSV-a je bila 25,64±5,38 cm/s, tokom istraživanja 26,94±5,31 cm/s, da bi na krajuistraživanja iznosila 35,84±5,73 cm/s. Tokom sva tri merenja došlo je do statistički značajnogpoboljšanja. Na početku i tokom istraživanja ispitanici ispitivane grupe su imali patološkevrednosti klaudikacione distance, da bi na kraju istraživanja ta vrednost bila u fiziološkimgranicama. Ustanovljeno je statistički značajno smanjenje pulsa tokom istraživanja i to ufiziološkim okvirima. Iako je došlo do statistički značajnog poboljšanja EFLV ipak su vrednosti nakraju istraživanja bile na donjim granicama fizioloških vrednosti. U toku istraživanja dobilo se istatistički značajno poboljšanje vrednosti pulsnog aortalnog pritiska. Iako je došlo do statističkiznačajnog poboljšanja FEV1 ipak su vrednosti na kraju istraživanja bile na donjim granicamafizioloških vrednosti.Zaključak - Vrednosti indeksa telesne mase ispitanika na kraju istraživanja su se statističkiznačajno smanjile. Prosečna vrednost holesterola i triglicerida, kao i prosečna vrednost PSV-a,BMI, EFLV, FEV1, kao i svih ostali poređenih parametara značajno se smanjila nakon obatretmana. Na osnovu dobijenih rezultata ustanovljeno je da je klaudikaciona distanca statističkiznačajno manja u odnosu na početne vrednosti. Poredeći efekte medikamentoznog tretmana saefektima kombinovanog terapijskog pristupa dolazi se do zaključka da su svi poređeni parametri,izuzev C-reaktivnog proteina u krvi, statistički značajno poboljšani na kraju kombinovanogtretmana u odnosu na vrednosti na kraju medikamentoznog tretmana., they represent a large social and economic burden. Diseases of peripheral arterial circulation can bedivided into two groups - the occlusive and non-occlusive disease, or functional impairment.Incidence of arterial disease of the lower extremities is strongly associated with age. Risk factorsfor peripheral arterial disease are similar to those that are important in the etiology of coronaryartery disease: obesity, smoking, dyslipidaemia, diabetes and hypertension. The most typicalpresentation of peripheral arterial disease is intermittent claudication, which is characterized withpain in the leaves, which increases during walking; the pain usually goes away in peace. All obesepatients with peripheral arterial disease of the lower extremities have an increased risk of futurecardiovascular incidents, and they require general secondary prevention in order to improve theirhealth forecasts. Physical activity represents the method of choice in patients with peripheralarterial disease of the lower extremities.Aim of the research: Compare the effects of programmed physical activity and medical therapy onhemodynamic and risk factors for cardiovascular diseases in patients with peripheral arterialdiseases of the lower extremities.Subjects and methods of research: A retrospective-prospective, clinically descriptive, controlledstudy was conducted on subjects of the Public Institution Health Care Centre of Sarajevo Canton–Specialist-consultative unit. Specialist-consultative unit represents secondary outpatient level ofhealth care. This study evaluated a period of 20 weeks (140 days). The study involved 75 subjects.At the beginning of the study, based on the findings of colour Doppler sonography of the pedalarteries, the findings of ejection fraction of the left ventricle, spirometry findings, values ofpulmonary aortic pressure and the determination of overweight - obesity subjects were included inthe research. In addition to ultrasound findings and spirometry findings, patients provided anexhaustive history of previous illnesses. Measurement of the body weight index, waistcircumference and claudication distance were performed. Lipid status and morning blood glucoselevel were performed for each patient. Prescribed or prolonged medicinal therapy was performedfor patients, and detailed instructions for everyday vasoactive walking program were given.Research resultsAt the beginning of the study, the average volume of the subjects' waistcircumference was 87.94 ± 3.07cm, after two weeks the average volume of the waist was 87.10 ±2.0 cm, and at the end of the study 84.96 ± 1.98cm. At the beginning of the study, subjects of thetested group had a body mass index of 28.93 ± 2.10 kg / m2. After two weeks of research andperformed therapy, the body mass index decreased and amounted to 28.36 ± 1.99 kg / m2, so that atthe end of the study, the average body mass index in the tested group was 27.26 ± 1.87 kg / m2.The mean blood glucose level at the beginning of the study was 5.77 ± 0.96 mmol / L, during thestudy this value was 5.42 ± 0.88 mmol / L, and at the end of the study, 5.30 ± 0.92 mmol / L. Thepostprandial blood glucose level at the beginning of the study was 7,48 ± 0,85 mmol / L, during thestudy, this value was 6.82 ± 0.62 mmol / L, and at the end of the study, 6.44 ± 0.64 mmol / L. Atthe beginning of the study, the HbA1c value was 5.52 ± 0.91%, during the study 5.32 ± 0.97%, andat the end of the study, 5.09 ± 0.73%. The C-reactive protein (CRP) mean at the beginning of thestudy was 3.77 ± 1.12mg / L, during the study, the value was 3.66 ± 1.36mg / L, and at the end ofthe study, this value was 3.61 ± 1.21mg / L. Paired t-test did not show a statistically significantreduction or an increase in CRP during the study. The average blood cholesterol of the subjects atthe beginning of the study was above the reference values and amounted to 6.58 ± 0.90 mmol / L.After two weeks of research and therapy, the value was 4.96 ± 0.46 mmol / L, and at the end of thestudy the value was 4.15 ± 0.54 mmol / L. The average triglyceride values at the beginning andduring the study were elevated so that at the end of the study they were within the reference values.VIIIThe difference between the values of leptin in male subjects at the beginning and at the end of thestudy were 2.66 ± 1.52 ng / ml (t = 3.024; p = 0.094) while there was no statistically significantdifference in female subjects. The average values of plasma viscosity were initially and during thestudy above the reference values, and at the end of the study this value was within the limits ofphysiological values. The mean values of PSV at the beginning and during the study were withinthe limits of pathological values, and at the end of the study the value was within the physiologicallimits. At the beginning of the study, the mean PSV value was 25.64 ± 5.38 cm / s, during the study26.94 ± 5.31 cm / s, and at the end of the study it was 35.84 ± 5.73 cm / s. During all threemeasurements statistically significant improvement was observed. At the beginning and during thestudy, the subjects of the tested group had pathological values of claudication distance, and at theend of the study this value was within the physiological limits. A statistically significant reductionin pulse was observed during the study, in physiological frameworks. Although there wasstatistically significant improvement in EFLV, however, the values at the end of the study were atthe lower limits of physiological values. During the study, statistically significant improvement inthe value of pulmonary aortic pressure was obtained. Although there was statistically significantimprovement in FEV1, the values at the end of the study were at the lower limits of physiologicalvalues.Conclusion - The values of the body mass index of subjects involved at the end of the study werestatistically significantly reduced. The average value of cholesterol and triglycerides, as well as theaverage value of PSV, BMI, EFLV, FEV1 as well as all other comparable parameters, decreasedsignificantly after both treatments. Based on the obtained results it was found that the claudicationdistance was statistically significantly lower than the baseline values. Comparing the effects ofmedicinal treatment with the effects of the combined therapeutic approach, it is concluded that allthe compared parameters, other than C-reactive protein in the blood, were statistically significantlyimproved at the end of the combined treatment compared to the values at the end of the medicinaltreatment.

Cilj istraživanja: Endotelni glikokaliks je izvanstanični polisaharidni omotač koji se nalazi na luminalnoj strani krvnih žila i važan je u održavanju integriteta krvnih žila. Modelom minimalno invazivne operacije (laparoskopska kolecistektomija) nastojali smo umanjiti druge utjecaje i izolirano promatrati utjecaj infuzijskih otopina na oštećenje glikokaliksa. Ispitanici, materijal i metode: u ovu studiju je bilo uključeno 120 bolesnika ASA (eng. American Society of Anesthesiologists) statusa I i II koji su randomizirano bili podijeljeni u tri ispitivane skupine od 40 ispitanika: restrikcijsku; liberalnu skupinu nižeg volumnog opterećenja i liberalnu skupinu većeg volumnog opterećenja. Praćene su koncentracije glavnih komponenti glikokaliksa, atrijski natriuretski peptid (ANP), markeri bubrežne i jetrene funkcije, plinska analiza u arterijskoj krvi, laktati, C-reaktivni protein i albumini u tri vremenske točke. Također su praćeni hemodinamski parametri neinvazivnom metodom kardiografske impedance i potrošnja kristaloida, volatilnih anestetika i analgetika. Rezultati: Nađene su značajno više koncentracije hijaluronske kiseline i sindekana-1 te veća sekrecija ANP-a u liberalnoj skupini većeg volumnog opterećenja u odnosu na ostale dvije skupine. Dokazana je pozitivna korelacija između sekrecije ANP-a i koncentracije glavnih komponenti glikokaliksa. Analiza hemodinamskih i laboratorijskih parametara nije pokazala znakova globalne i splanhničke hipoperfuzije ni u jednoj ispitivanoj skupini. Potrošnja kristaloida, volatilnih anestetika i opioida bila je statistički značajno manja u restrikcijskoj u odnosu na preostale dvije liberalne skupine. Zaključak: Mjerenje glavnih komponenti glikokaliksa u cirkulirajućoj krvi može biti pokazateljem intraoperacijskoga volumnog preopterećenja za vrijeme laparoskopskih operacija. Restrikcijska volumna nadoknada za vrijeme laparoskopske kolecistektomije je opravdana, sigurna i ekonomski isplativija u odnosu na liberalne načine volumne nadoknade. Objectives: Endothelial glycocalyx is the extracellular polysaccharide layer located on the luminal side of blood vessels. It is very important in maintaining the integrity of blood vessels. By the model of minimally invasive surgery (laparoscopic cholecystectomy) we have minimized other influences and isolated observed the impact of infusion solutions on the endothelial glycocalyx layer damage. Patients and Methods: The study included 120 patients with American Society of Anesthesiologists’ (ASA) class I and II, who were randomly assigned to one of three groups: Restrictive group, Low liberal group and High liberal group. Each group had 40 patients. We measured patients’ concentrations of glycocalyx constituents, atrial natriuretic peptide (ANP), markers of kidney and liver function, blood gas analysis, lactates, C-reactive protein (CRP), and albumine at three time points. We also measured noinvasive haemodynamics by cardiographic bioimpedance method, along with the patients’ consumption of crystalloids, volatile anesthetics, and analgesics. Results: We found a significantly higher concentrations of hyaluronic acid and syndecan-1 and more ANP secretion in the High liberal group than in the other groups. We also observed a positive correlation between ANP secretion and glycocalyx constituents concentration. Analysis of haemodynamic and laboratory markers revealed no signs of global or splanchnic hypoperfusion in any of the examined groups. There was no significant difference in the duration of surgery and anesthesia, but consumption of crystalloids, volatile anesthetics, and opioids was significantly lower in the restrictive group compared with the low and high liberal groups. Conclusion: Measuring the endothelial glycocalyx constituents in circulating blood could be a marker of intraoperative volume overload during laparoscopic operations. Restrictive fluid therapy during laparoscopic cholecystectomy is justified, safe, and more cost-effective than other options.

Darba autors: Evija Perse. Bakalaura darbs. „Politraumas protokolu pielietojums radiogrāfera praksē”. Izstrādāts Latvija Universitātē, Medicīnas fakultātē, Rīgā, 2018.gadā. Darba mērķis ir noskaidrot politraumas protokola pielietojumu, veicot datortomogrāfijas izmeklējumu. Lai sasniegtu pētījuma mērķi, tiek izvirzīti sekojoši darba uzdevumi: 1.apkopot un analizēt medicīnisko literatūru par traumu cēloņiem, mehānismu, veidiem; 2.izpētīt un analizēt pieņemtos standartus par radioloģisko izmeklējumu protokoliem politraumas pacientiem; 3.noskaidrot biežāk pielietotos izmeklējumu protokolus politraumas gadījumā; 4.izveidot datu analīzes kritērijus, lai apzinātu protokolu izvēli; 5.apkopot un analizēt iegūtos datus; 6.apkopot iegūtos materiālus un izdarīt secinājumus. Lai izpildītu izvirzītos uzdevumus tika veikta literatūras apskats un dokumentu materiāla apkopojums, ar kvantitatīvo pētījuma metodi. Bakalaura darbs sastāv no anotācijas, ievada, četrām nodaļām ar sešām apakšnodaļām, kurās atspoguļots literatūras apskats par politraumas pacientu izmeklēšanas tendencēm neatliekamajā radioloģijā, standartu un vadlīniju pielietojumu, veikts pētījuma rezultātu apkopojums par standartu pielietojumu ārstniecības iestādē un iegūto datu interpretācija un analīze. Bakalaura darba noslēgumā ir apkopoti secinājumi par darba tematu, balstoties uz izpētīto literatūru un iegūto informāciju par standarta radioloģisko izmeklējumu protokolu pielietošanu politraumas gadījumā. Darbs uzrakstīts latviešu valodā, sastāv no 34 lappusēm, 9 attēliem, 3 pielikumiem. ATSLĒGVĀRDI: /politrauma/hemodinamika/protokols/diagnostika/radiografers/, Evija Perse Bachelor’s work, “Used protocols in case of polytrauma for radiographers”, Latvian University, Faculty of medicine, Riga, 2018. The aim of work is to find out used investigation protocols in case of polytrauma in computer tomography. To achieve the aim of the work such objectives were set up tasks: 1. Collect and analyze the medical literature about case of trauma, trauma causes/mechanism and type; 2. Research and analyze standards for examinations protocols in radiology for polytrauma patients; 3. Research most of used examinations protocols in polytrauma; 4. Make criteria for research about used protocols in radiographer practice; 5. To summarize and analyze results; 6. To work out conclusions and suggestions. In order to complete the tasks, were performed a literature review and a compilation of documentary material, with a quantitative research method. The Bachelor’s work consists of summary, introduction, 4 chapters with 6 subdivisions, where the literature review are about examinations tendencies for polytrauma patient in emergency radiology used standards and guidelines. Results of research summarize about used standards in hospital, make a interpretation and analyze data. At the end of the bachelor thesis, finished with conclusions on the topic of the work, based on the literature and information about the standard used examination protocols in the case of polytrauma. The bachelor work is written in Latvian consists of 34 pages, 9 images, and 3 annexes. KEY WORDS: /polytrauma/hemodynamic/protocol/diagnostic/radiographer/

Cilj istraživanja: Cilj ovog istraživanja bio je odrediti učinak akutnog iscrpljujućeg treninga na vaskularnu reaktivnost i endotelnu funkciju mikrocirkulacije kože u populaciji profesionalnih veslača i sedentarnih ispitanika, te utvrditi potencijalnu ulogu promjene hemodinamskih parametara i/ili razine oksidativnog stresa u regulaciji akutnim treningom promijenjenog mikrovaskularnog protoka krvi. Nacrt studije: Eksperimentalno istraživanje s nerandomiziranom pretest- posttest kontrolnom skupinom. Ispitanici i metode: Antropometrijske mjere, sastav tijela te biokemijski i hemodinamski parametri bili su mjereni u 18 mladih zdravih sedentarnih ispitanika (Sedentarni) i 20 profesionalnih veslača (Veslači) koji su podvrgnuti akutnom iscrpljujućem treningu na veslačkom ergometru. Protok krvi u mikrocirkulaciji kože mjeren je metodom mjerenja protoka laser Dopplerom (eng. laser Doppler flowmetry, LDF) u odgovoru na vaskularnu okluziju (post-okluzivna reaktivna hiperemija, PORH) te iontoforezu acetilkolina (ACh% dilatacije) i natrijevog nitroprusida (SNP% dilatacije) prije i poslije akutnog treninga. Razina oksidativnog stresa (reaktivne tvari tiobarbituratne kiseline, TBARS) i antioksidativni kapacitet (sposobnost plazme da reducira željezo, FRAP) plazme mjereni su kod svih ispitanika prije i poslije akutnog treninga. Rezultati: Bazalno su Veslači imali značajno niži dijastolički krvni tlak (DBP) i puls, a veći udarni volumen srca (UV), PORH i endotel- ovisnu vazodilataciju mikrocirkulacije kože u usporedbi sa Sedentarnima. Akutni iscrpljujući trening doveo je do potpunog iscrpljenja i uzrokovao je značajan porast sistoličkog krvnog tlaka, DBP, pulsa i UV, a smanjenje ukupnog perifernog otpora u obje skupine. Akutni iscrpljujući trening izazvao je značajno smanjenje PORH-a i ACh-inducirane vazodilatacije kod Veslača, ali povećanje ACh- inducirane vazodilatacije kod Sedentarnih ispitanika. SNP-inducirana vazodilatacija nije bila značajno promijenjena akutnim treningom niti kod Veslača ni Sedentarnih. Antioksidativni se kapacitet značajno povećao samo kod Sedentarnih nakon akutnog treninga. Zaključak: Akutni iscrpljujući trening smanjio je mikrovaskularnu reaktivnost i endotelnu funkciju mikrocirkulacije kože Veslača, ali ne i sedentarnih vjerojatno zbog 1) više veslačkih stadija i konačnog intenziteta vježbanja koji su ostvatrili veslači ; 2) većeg porast arterijskog tlaka veslača tijekom akutnog treninga ; i/ili 3) nižeg antioksidativnog kapaciteta uslijed akutnog treninga kod Veslača u usporedbi sa Sedentarnim ispitanicima.

Ciljevi istraživanja: Izmjeriti razlike u demografskim pokazateljima, usporediti vrijednosti plućnog i perifernog vaskularnog otpora te vrijednosti troponina kod bolesnika podvrgnutih operaciji aortokoronarnog premoštenja, zamjeni zalistaka ili objema operacijama. Nacrt studije: retrospektivno istraživanje Materijal i metode: U istraživanje je bilo ukljućeno 108 kardiokirurških bolesnika operiranih od 4. siječnja 2016. do 25. svibnja 2016. kojima su analizirane povijesti bolesti i ispisi hemodinamskih vrijednosti. Bolesnici su bili podijeljeni u tri skupine s obzirom na operacijski zahvat. U ispitanim skupinama uspoređeni su demografski pokazatelji, laboratorijski nalazi i hemodinamske vrijednosti. Svi podatci analizirani su uporabom t-testa i χ2 test, Fisherova egzaktnog test, ANOVA testa te Pearsonove korelacije. Rezultati: Ispitivane skupine nisu se razlikovale po dobi i spolu. Najčešći komorbiditet u svim skupinama bila je hipertenzija (94, 44 %). Prosječne vrijednosti indeksa tjelesne mase bile su veće od 29. Vrijednosti eritrocita (E), hemoglobina (Hg) i trombocita (Trc) bile su najmanje kod bolesnika kojima je učinjena operacija valvule (E = 3, 42, Hg = 102, 75, Trc = 110, 34). Najviše vrijednosti troponina imala je skupina bolesnika kojima su učinjene obje operacije, a najniže kojima je učinjeno aortokoronarno premoštenje. Postoji pozitivna povezanost između troponina, plućnog i perifernog vaskularnog otpora, troponina i srednjeg tlaka u plućnoj arteriji, a negativna između troponina, udarnog i minutnog volumena (p

Većina aneurizmi abdominalne aorte (AAA) sadrži intraluminalni tromb (ILT) nataložen na mjestu proširenja stijenke. Pokazano je da ILT ima značajan biokemijski i mehanički utjecaj na stijenku aorte i stoga je bitno modelirati njegovo stvaranje i utjecaj u analizi rasta i promjene strukture (growth and remodeling, G&R) aorte. U ovom radu razvijen je algoritam za spajanje G&R analize AAA pomoću konačnih elemenata i simulacije strujanja krvi pomoću konačnih volumena. Algoritam radi tako da nakon određene promjene u geometriji aneurizme (npr. određeno povećanje najvećeg promjera) zaustavlja G&R analizu te pokreće simulaciju strujanja krvi na trenutnoj geometriji aneurizme. Simulacija strujanja izračunava vremenski osrednjeno posmično naprezanje na stijenci i na mjestu gdje je ono manje od granične vrijednosti, algoritam dodaje sloj konačnih elemenata tromba te nastavlja G&R analizu. Tijekom jedne G&R analize pokreće se više simulacija strujanja krvi, pri čemu se G&R analiza odvija na vremenskoj skali u godinama, a simulacija strujanja krvi u sekundama. Konačni elementi s ugrađenim G&R modelom omogućuju nam analizu razvoja fuziformne i sakularne aneurizme, pri čemu uz pomoć razvijenog algoritma možemo dodatno modelirati stvaranje i rast tromba te analizirati njegov biokemijski i mehanički utjecaj na stijenku aorte.

Namen diplomskega dela je bil raziskati spremembe v sistemski in lokalni hemodinamiki človeških obtočil med manevrom oddaljenega ishemičnega prekondicioniranja. Predvsem sistoličnega in diastoličnega krvnega tlaka, minutnega iztisa srca, frekvence srca in regionalne tkivne oksigeniranosti. Izvedli smo eksperimentalno prospektivno raziskavo, izvedba pa je potekala v simulacijskem okolju. Gibanje vrednosti parametrov sistemske hemodinamike smo spremljali z monitorjem Task Force, reginalno oksigeniranost pa z napravo INVOS™ 5100c. Prvi nam ponuja kontinuirano merjenje krvnega tlaka v realnem času skupaj z merjenjem minutnega iztisa in frekvence srca s pomočjo bioimpendančne metode. Manever prekondicioniranja pa smo izvedli s pomočjo običajne manšete za oscilometrično merjenje krvnega tlaka. Ugotovili smo porast sistoličnega tlaka pri polovici in stagnacijo pri drugi polovici preiskovancev hkrati pa porast diastoličnega krvnega tlaka pri vseh preiskovancih. Frekvenca srca je porasla pri dveh preiskovancih, pri istih pa hkrati povzročila porast v minutnem iztisu srca. Pri preostalih so vrednosti stagnirale. Zabeležili smo močan padec tkivne oksigeniranosti pri vseh preiskovancih v fazi ko je manšeta napolnjena in preseganje začetnih vrednosti v fazi reoksigenacije kar poznamo kot pojav reakcijske hiperemije. Povzamemo lahko da manever oddaljenega prekondicioniranja sicer vpliva na parametre sistemske hemodinamike v pričakovani smeri vendar ne povzroča močnih nenadnih sprememb, ki bi utegnile ogrožati bolnika. Drugače je pri regionalni hemodinamiki kjer so bile spremembe precejšnje (tudi 50% razlike v rSO2). Raziskava je bila izvedena na zdravih posameznikih pri zavesti, zato ni bilo moč popolnoma izključiti psiholoških vplivov na parametre, ki so kljub konstantnem fizičnem okolju vsekakor bili prisotni. The purpose of the study was to research changes in systemic and regional hemodynamics during the remote ischemic preconditioning. Mostly we focused on systolic and diastolic blood pressure, cardiac output, heart rate and regional tissue oxygenation. Experimental prospective research was made in the environment of simulation laboratory. The flow of systemic hemodynamic parameters was being monitored with Task Force monitor. At the mean time we monitored tissue oxygenation with INVOS™ 5100c device. The first one possesses the option of real time continuous blood pressure measurement, as well as measurement of heart rate and cardiac output through bioimpedance method. We managed to improvise the preconditioning maneuver with an ordinary cuff, normally used for non-invasive blood pressure measurement. We found out that systolic blood pressure arose by two volunteers and remained the same by the other two. Meanwhile diastolic blood pressure arose by all four volunteers. Heart rate arose by two volunteers as well, causing consequent rise of cardiac output for same two volunteers. At the same time heart rate remained the same by the other two as well as cardiac output. Regional oxygenation suffered severe decline when cuff was filled with air with noticeable rebound quickly after the cuff release. Not only did it reach the original value but it surpassed it instead. It is phenomena known as reactive hyperemia. All in all we are able to conclude that remote ischemic preconditioning maneuver has an influence on systemic hemodynamics in expected way, but it does not cause changes of an extent that could possibly endanger safety of a patient. It is a bit different by regional hemodynamics where we monitored up to 50% difference in tissue oxygenation (rSO2) during various phases of the research. Research included healthy conscious volunteers thus we could not fully eliminate psychological influence on parameters despite constant environment.

Ovaj rad govori o modeliranju krvotoka korištenjem metode transmisijske linije i osnovnih izraza hemodinamike. Uvodno poglavlje govori o ulozi koju modeliranje krvotoka ima u medicini, te daje opis kardiovaskularnog sustava sa naglaskom na arterijsko stablo. Drugo poglavlje opisuje i daje pregled nekih od osnovnih izraza korištenih u hemodinamici i arterijskoj hemodinamici. Treće poglavlje daje objašnjenje matematičkog modeliranja, te daje pregled hemodinamičkih modela korištenih za modeliranje krvotoka. U nastavku rada je analiza modela arterijskog stabla. Za modeliranje arterijskog stabla je korištena metoda transmisijske linije. Dana je proizvoljna zrakasta konstrukcija modela, te pregled svih ulaznih parametara potrebnih za analizu. Također, napravljen je program za analizu korištenjem programskog jezika MATLAB. Rezultati, izlazni podaci, analize su prikazani grafički u obliku dijagrama, te se mogu koristit za usporedbu sa rezultatima drugih analiza iz literature. This paper speaks about modeling of bloodstream using the transmission line method and basic hemodynamics terms. The introductory chapter discusses the role that modeling of bloodstream has in medicine, and provides a description of the circulatory system with an emphasis on the arterial tree. The second chapter describes and summarizes some of the basic terms used in hemodynamics and arterial hemodynamics. The third chapter gives an explanation of mathematical modeling, and provides an overview of the hemodynamics models used for modeling of bloodstream. Further in paper there is an analysis of arterial tree model. Transmission line method is used for modeling of arterial tree. An arbitrary radial construction of model is given, and overview of all the input parameters required for analysis. Also, program to analyze model is created by using programming language MATLAB. Results, output data, of analysis are presented graphically in the form of diagrams, and therefore can be used for comparison with the results of other analyzes from the literature.

Cerebralne aneurizme su patološka proširenja arterijske stijenke. Nalazimo ih u 2-3% ljudi. Poznati rizični čimbenici uključuju pušenje cigareta, hipertenziju i pozitivnu obiteljsku anamnezu. Hemodinamika već godinama igra ključnu ulogu u stvaranju i razvoju cerebralnih aneurizmi. Nerupturirane cerebralne aneurizme su češće u žena u omjeru 3:1 . Cerebralne aneurizme možemo podijeliti prema veličini i obliku.Tri glavna oblika su vrećaste, vretenaste i difuzne aneurizme. Cerebralne aneurizme su sporadične lezije, međutim, rijetke su obiteljske forme cerebralnih aneurizmu povezane s autosomno-dominantom policističnom bolesti bubrega tipa IV, Ehlers-Danlos sindromom, moyamoya bolešću i arteriovenskim malformacijama mozga. Cerebralne aneurizme su najčešće smještene u prednjoj moždanoj cirkulaciji. Većina je cerebralnih aneurizmi asimptomatska dok ne rupturiraju. Međutim, nerupturirane aneurizme mogu postati simptomatske. Simptomi uključuju glavobolju, neuropatije kranijalnih živaca i disfunkciju piramidnog trakta. Najčešće se cerebralne aneurizme prezentiraju subarahnoidalnim krvarenjem. Dijagnoza SAH-a se uglavnom postavlja CT-om, CT ili kateter angiografijom. Cerebralne aneurizme, nerupturirane ili rupturirane, mogu se liječiti otvorenom operacijom i endovaskularno, ili kombinacijom te dvije metode. Kirurško „klipiranje“ ili endovaskularno postavljanje uzvojnice su najčešće korištene tehnike u liječenje cerebralnih aneurizmi. U većini slučajeva, anatomski čimbenici, kao što su veličina i lokalizacija, određuju koja će metoda liječenja biti najpogodnija za pacijenta. Cerebal aneurysms are pathological dilatations of the arterial walls. They occur in 2-3% of humans. Known risk factors include smoking, hypertension and postive family history for intracranial aneurysms. Hemodynamics has been proposed for many years as a fundamental player in the process of aneurysms formation and progression.Unruptured intracranial aneurysms are more common in women with a 3:1 ratio of women to men. Cerebral aneurysms are classified both by size and shape. The 3 major types of true intracranial aneurysms are saccular, fusiform, and diffuse. Intracranial aneurysms are sporadically lesions; however, a rare familial form has been associated with conditions like autosomal dominant polycystic kidney disease, Ehlers-Danlos syndrome type IV, moyamoya disease and arteriovenous malformations of the brain. Aneurysms located in the anterior circulation are more frequent. Most aneurysms do not cause symptoms until they rupture. Some unruptured aneurysms can become symptomatic. Symptoms include headache, cranial neuropathies and pyramidal tract disfunction. The most common presentation of intracranial aneurysm is subarachnoid hemorrhage.Diagnosis of SAH is primarily by CT, CT or catheter angiography. Aneurysms, whether ruptured on unruptured, can be treated by open surgery or endovasculary, or by combining these two modalities. Surgical clipping and endovascular coiling are the most commonly used techniques for aneurysm treatment. In many cases, anatomic considerations, such as size or location determine which treatment is most approppriate for the patient.

Cilj Cilj ovog rada je opisati hemodinamske poremećaje i postupke koje medicinske sestre/tehničari moraju provodit kod ovakvih pacijenata. Postupci se tiču zdravstvene njege bolesnika, sudjelovanja u monitoringu i liječenju bolesnika. Rasprava Medicinske setre i tehničari provode najviše vremena uz bolesnika, i oni su ti koji prvi primjete promjene na bolesniku, o tome obaviještavaju liječnika i provode ordiniranu terapiju. Od iznimne važnosti je dobro poznavanje znakova i simptoma hemodinamičkih poremćaja i tumačenja vrijednosti koje dobivamo monitoringom. Ispravnim provođenjem tehničkih postupka smanjuje se mogućnost infekcije i drugih komplikacija koje su vrlo česte kod ovakvih bolesnika (npr.zbog invazivnog monitoringa, intravenske nadoknade tekućine...). Poznavanjem svojstava lijekova i tekućina za nadoknadu, medicinske sestre mogu efikasnije i brže reagirati i izvršiti liječničke naloge. Zaključak Bitno je da medicinske sestre/tehničari kroz cijeli radni vijek provode usavršavanje starih i usvajanje novih znanja i vještina. Medicinska tehnologija i procesi u zdravstvenoj njezi bolesnika se razvijaju iz dana u dan. To se možda najviše odnosi na odjele intezivne njege. Medicinske sestra/tehničari koji su u toku sa najnovijim saznanjima u medicini i koji imaju razvijeno kritičko mišljenje su nezamjenjiv dio bolničkog tima.

There is limited evidence showing that elevated arterial blood pressure in surgical patients may be associated with increased perioperative risk; however, cardiovascular instability frequently occurs during anesthesia. The most commonly used anesthetic agents, both intravenous and inhalation ones, produce a decrease in arterial blood pressure. Magnesium, acting as a natural calcium-channel blocker, induces direct and indirect vasodilatation, thus playing a role in the treatment of arterial hypertension. In this research, we assessed the effects of magnesium sulfate on cardiovascular stability in patients undergoing diverse planned surgical procedures (abdominal, orthopedic, urology) under general balanced anesthesia, who were diagnosed with arterial hypertension grade 1 and 2. The research encompassed 100 patients of both sexes, aged from 20 to 65. Immediately before induction of anesthesia with propofol, the patients in the experimental group (50 study subjects) received 30 mg/kg bolus dose and magnesium sulfate infusion at 10 mg/kg/h, whereas the subjects in the control group (50 patients) were administered normal saline. Anesthesia was achieved and maintained with sevoflurane, fentanyl and rocuronium. The hemodynamic variables of mean arterial pressure and heart rate were measured every five minutes, starting immediately before magnesium infusion. Statistical analysis of the categorized values of mean arterial pressure and heart rate revealed a statistically significant between-group difference at 60th and 90th minute of anesthesia. In conclusion, magnesium sulfate as an adjuvant to anesthesia in patients with arterial hypertension reduces hemodynamic changes during anesthesia., Postoje određeni dokazi koji ukazuju na postojanje povišenog perioperacijskog rizika kod kirurških bolesnika s povišenim arterijskim tlakom, a kardiocirkulacijska nestabilnost je česta pojava tijekom anestezije. Najčešće upotrebljavani intravenski i inhalacijski anestetici izazivaju snižavanje arterijskog tlaka. Magnezij kao prirodni blokator kalcijevih kanala izaziva vazodilataciju te može imati ulogu u terapiji hipertenzije. U istraživanju su ispitani učinci magnezij sulfata na kardiocirkulacijsku stabilnost kod bolesnika s hipertenzijom prvog i drugog stupnja koji su podvrgnuti različitim elektivnim operacijskim zahvatima (abdominalna, ortopedska kirurgija, urologija) u općoj balansiranoj anesteziji. Studija je obuhvatila sto bolesnika oba spola u dobi od 20 do 65 godina. Neposredno prije intravenskog uvoda u opću anesteziju propofolom bolesnici u eksperimentalnoj skupini dobili su magnezij sulfat u dozi od 30 mg/kg intravenski, a zatim je infuzija magnezij sulfata nastavljena po stopi od 10 mg/kg/h, dok su bolesnici u kontrolnoj skupini dobili 0,9%-tnu otopinu natrij klorida. Anestezija se održavala primjenom sevoflurana i fentanila, a mišićna relaksacija primjenom rokuronija. Hemodinamski parametri, srednji arterijski tlak i srčana frekvencija mjereni su svakih 5 minuta, počevši neposredno prije infuzije magnezij sulfata. Statistička analiza pokazala je statistički značajnu razliku između eksperimentalne i kontrolne skupine u vrijednostima srednjeg arterijskog tlaka i srčane frekvencije u 60. i 90. minuti anestezije. Magnezij sulfat kao adjuvans kod bolesnika s hipertenzijom smanjuje hemodinamske promjene tijekom anestezije.