The aim of this study was to assess preoperative airway history data and single anthropometric screening tests of difficult face mask ventilation (FMV) and difficult direct laryngoscopy intubation ...(DLI) in otorhinolaryngological surgery. Final analysis included 62 patients aged ≥14 years undergoing elective surgery with endotracheal intubation at a single center during a one-month period. Data on difficult intubation history, airway symptoms and pathology related to difficult airway were prospectively collected. Han scoring classification of FMV and Intubation Difficulty Score (IDS) were used. There were 14 (22.6%) patients with a history of current airway tumors or abscesses. Only two (3.2%) patients were preoperatively evaluated as anticipated difficult airway. Both were slightly difficult to ventilate and scored IDS 5 and IDS 8. FMV was graded as easy in 50 (80.5%), slightly difficult in 10 (16.1%) and difficult in 2 (3.2%) cases. There were 29 (46.78%) slightly difficult DLIs and one (1.6%) case of difficult DLI. The study confirmed clinically relevant incidence of difficulties with FMV and DLI in otorhinolaryngologic surgery patients. However, there should be stronger evidence to identify a single preoperative variable predicting difficult airway.
Značajke uznapredovale Behterevljeve bolesti (ankilozirajući spondilits) su sve veća osifikacija kralježnice od donjih, lumbalnih dijelova prema višim, cervikalnim što uzrokuje prvo nemogućnost ...izvođenja spinalnog bloka u lumbalnoj regiji, a kasnije, zbog ukočenosti vratnog dijela kralježnice, otežanu intubaciju zbog nemogućnosti ekstenzije i/ili fleksije vrata u tijeku direktne laringoskopije i intubacije. S druge strane, ventilacija na masku je obično izvediva. Ovdje prikazujemo 77-godišnjeg bolesnika koji je bio predviđen za elektivnu operaciju ingvinalne hernije, a čiji je ankilozirajući spondilitis u posljednje vrijeme jako uznapredovao. U skladu s nedavno prihvaćenim “Mainz algoritmom” najprije smo pokušali intubirati fleksibilnim fiberbronhoskopom na budnom bolesniku. Bronhoskop je lako prošao sve do bifurkacije traheje, ali je neočekivano postavljanje endotrahealnog tubusa zapelo na preuskoj nosnici zbog prijeloma nosa koji je bolesnik zadobio u dobi od 8 godina. Zato smo izvukli fiberbronhoskop i nakon indukcije opće anestezije uspjeli intubirati u prvom pokušaju rigidnim fiberskopom po Bonfilsu.
Advanced Bechterew's disease presents with increasing ossification of spinal column, from lower lumbar segments upwards, first causing impossibility to place spinal block in lumbar region, and later, ...due to stiffness of cervical spine, difficult intubation because of inability to extend and/or flex the neck during direct laryngoscopy and intubation. Mask ventilation, on the other hand, usually is possible. We report a case of a 77-year-old man scheduled for elective hernioplasty, with recently advanced Bechterew's disease. According to the recently accepted Mainz algorithm, we first intended to perform awake intubation through the nose by fiber bronchoscope. The bronchoscope passed easily down to tracheal bifurcation, but placing the endotracheal tube was unexpectedly impossible due to the consequences of broken nose the patient had suffered at the age of 8. Fiber bronchoscope was therefore retracted, and we used the Bonfils rigid fiberscope after induction of general anesthesia, achieving intubation in first attempt.
Zbrinjavanje dišnog puta kod politraumatiziranog bolesnika s teškim deformitetima kralježnice i prsnog koša zahtijeva detaljan pregled anatomskih karakteristika glave, vrata i dišnih putova, kao i ...konfiguracije prsnog koša prije pokušaja endotrahealne intubacije. To omogućava liječniku da se pripremi za zbrinjavanje eventualnog otežanog dišnog puta. Prikazuje se slučaj 50-godišnjeg politraumatiziranog bolesnika s višestrukim prirođenim deformitetima kostiju povezanim sa sindromom osteogenesis imperfecta i teškom kifoskoliozom, nesposobnog da leži na leđima zbog velikog gibusa, koji je uspješno intubiran u prvom pokušaju uz upotrebu videolaringoskopa, samo uz blagu sedaciju. U slučaju zbrinjavanja bolesnika s višestrukim deformitetima videolaringoskop ili Bonfils rigidni endoskop bi se trebao redovno rabiti zbog sigurnosti intubacije u prvom pokušaju i izbjegavanja moguće aspiracije želučanog sadržaja.
Airway management in a polytraumatized patient with severe spinal and thoracic deformities demands detailed investigation of anatomical characteristics of the head, neck and airways, as well as ...thoracic configuration, before attempting endotracheal intubation. This enables the physician to predict a difficult airway and prepare for difficult airway management. We present a case of a 50-year-old polytraumatized patient with multiple congenital bone deformities associated with the syndrome of osteogenesis imperfecta and severe kyphoscoliosis, unable of lying on his back due to gibbus, who was successfully intubated in first attempt using video laryngoscope and only mild sedation. In patients with such severe multiple deformities, the use of video laryngoscope or Bonfils rigid endoscope should be mandatory in order to ensure success of intubation in first attempt and to avoid the possible aspiration of gastric contents.
This clinical report describes an emergency case of a 49-year-old man, ASA E III status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of ...difficult intubation (Mallampati test Class III, short thyro-mental (< 6 cm) and sterno-mental distance (<10 cm) with limited mouth opening (inter-incisor gap < 3 cm) were associated with significant comorbidity (rheumatoid arthritis, heart disease, obesity (body mass index 32.6 kg m-2), cervical spine mobility and generalized vascular disease). A specialist experienced in airway management decided on one attempt of Bonfils fiberoptic intubation as primary intervention and urgent tracheotomy, if needed, as secondary intervention. Immediately after assuming supine position on the operating table, the patient lost consciousness and cardiac arrest developed. Successful intubation with oxygenation was followed by cardiopulmonary resuscitation. Upon stabilization of the patient's vital functions, urgent surgery was performed. In the emergency case presented, we succeeded quickly to secure the airway with Bonfils fiberoptic intubation, which allowed for appropriate oxygenation and starting resuscitation. The high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands.
Opisuje se hitan slučaj 49-godišnjeg bolesnika statusa ASA E III s jasnim kliničkim simptomima akutnog abdomena i ileusa, koji je bio predviđen za hitan kirurški zahvat. Uza začajan komorbiditet ...(reumatoidni artritis, bolesti srca, pretilost (indeks tjelesne mase 32.6 kg m-2), deformitet vratne kralježnice te generaliziranu aterosklerozu) kliničkim pregledom otkriveni su i prediktori teške intubacije (Mallampati test klasa III ., kratka tiro-mentalna (<6 cm) i sterno-mentalna udaljenost (<10 cm) s ograničenim otvaranjem usta (razmak između sjekutića <3 cm). Iskusni anesteziolog u zbrinjavanju dišnog puta primarno se odlučio za fiberoptičku intubaciju Bonfilsom, odnosno sekundarnu hitnu traheotomiju ako se intubacija Bonfilsom ne uspije učiniti iz prvoga pokušaja. Neposredno nakon premještaja bolesnika na operacijski stol te njegovog namještanja u leđni položaj bolesnik gubi svijest uz razvoj asistolije srca. Odmah je izvedena uspješna intubacija, omogućena oksigenacija bolesnika praćena kardiopulmonalnom reanimacijom. Nakon stabilizacije vitalnih funkcija bolesnika uspješno je dovršen i hitan kirurški zahvat. U prikazanom hitnom slučaju smo fiberoptičkom intubacijom uz Bonfils uspješno i brzo osigurali dišni put te time osigurali dostatnu oksigenaciju i brz početak reanimacije. U ovom slučaju je pravodobna intubacija u rukama iskusnog anesteziologa bila presudna za zaštitu dišnoga puta bolesnika od prijeteće aspiracije uz prisutan ileus.
It is not clear if any technique of regional anesthesia for carotid endarterectomy has an advantage over another. Therefore, we analyzed analgesic efficacy side effects and complication rate in ...patients undergoing carotid surgery either under combined (deep and superficial) or superficial cervical block alone. Data on 324 patients that received either combined (n = 107) or superficial (n = 216) cervical block were prospectively analyzed. Data were collected on the intraoperative Verbal Analog Score (VAS), arterial pressure and heart rate. Analgesic efficacy was additionally assessed by the dose of supplemental 1% lidocaine and fentanyl and time before the first analgesic was administered at Intensive Care Unit. During surgery, VAS was slightly higher in the superficial group (median 0.6, range 0-3.9) than in the combined group (median 0.4, range 0-2.4; p < 0.001). The median supplemental lidocaine dose during the operation was higher in the superficial block group (2.4 mg/kg, range 1.1-3.5) than in the combined group (2.1, range 0.5-3.4 mg/kg; p < 0.001). Supplemental fentanyl was also higher in the superficial block group. There were no between-group differences in the time before the first postoperative analgesic, postoperative VAS and block-related complication rate. Accordingly combined block provided a slightly better analgesia during the surgery which was probably clinically irrelevant. There was no difference in postoperative analgesia and hemodynamic stability. So far, this is the largest prospective study in which superficial cervical block was found to be as efficacious as combined block which is associated with a considerably higher risk of complications.
Zasad još nije jasno ima li ijedna tehnika regionalne anestezije za karotidnu endarterektomiju prednosti pred drugima. Stoga smo analizirali djelotvornost analgezije, nuspojave i stopu komplikacija ...kod bolesnika podvrgnutih operaciji karotide pod kombiniranom (dubokom i površinskom) ili samo površinskom blokadom vratnog pleksusa. Prospektivno smo analizirali podatke za 324 bolesnika koji su primili kombinirani (n=107) ili površinski (n=216) blok vratnog pleksusa. Prikupljeni su podaci za intraoperacijsku vrijednost VAS (Verbal Analog Score), arterijski tlak i srčanu frekvenciju. Djelotvornost analgezije dodatno se procjenjivala prema dozi dopunskog 1%-tnog lidokaina i fentanila te vremenu proteklom do prvog davanja analgetika u Jedinici intenzivne skrbi. Za vrijeme operacije je VAS bio nešto viši u skupini s površinskom blokadom (medijan 0,6, raspon 0-3,9) u odnosu na skupinu s kombiniranom blokadom (medijan 0,4, raspon 0-2,4; p<0,001). Medijan doze dopunskog lidokaina tijekom operacije bio je viši u skupini s površinskom blokadom (2,4 mg/kg, raspon 1,1-3,5 mg/kg) negoli u skupini s kombiniranom blokadom (2,1 mg/kg, raspon 0,5-3,4 mg/kg; p<0,001). Doza dopunskog fentanila bila je također viša u skupini s površinskom blokadom. Nije bilo razlike među skupinama u vremenu do prvog poslijeoperacijskog analgetika, poslijeoperacijskoj vrijednosti VAS i stopi komplikacija povezanih s blokadom. Zaključeno je kako kombinirana blokada osigurava nešto bolju analgeziju tijekom operacijskog zahvata, no razlika je vjerojatno klinički nevažna. Nije bilo razlike u poslijeoperacijskoj analgeziji i hemodinamskoj stabilnosti. Dosad je ovo najveća prospektivna studija u kojoj je utvrđeno da je površinska blokada vratnog pleksusa jednako djelotvorna kao kombinirana blokada, koja je udružena sa znatno većim rizikom od komplikacija.
Udaljena endarterektomija predstavlja endovaskularni pristup i minimalno invazivni postupak u liječenju obliteracije bedrene arterije. Prikazane su uspješno učinjene revaskularizacije površinske ...bedrene arterije primjenom postupka udaljene endarterektomije upotrebom Mollring Cuttera uz postavljanje endoluminalnog stenta na distalnoj stubi. Bolesnik u dobi od 72 godine s obliteracijom desne bedrene arterije te klaudikacijskim tegobama operiran je ovim endovaskularnim postupkom. Operacijski zahvat trajao je 70 minuta. Poslijeoperacijski tijek protekao je uredno. Bolesnik star 64 godine s obliteracijom bedrene arterije i ishemijskim ulkusom na istoj nozi operiran je istim postupkom. Kirurški zahvat trajao je 68 minuta. Pri otpustu imao je uredne periferne pulzacije.
