Tracheal measurements in the intensive care unit (ICU) are important for the choice of endotracheal tube and may correlate with patient demographic characteristics and infections. The study included ...42 surgical patients, age 60 48-71 years, who underwent diagnostic chest computed tomography (CT) scans during treatment in the ICU, Osijek University Hospital, in 2019 and 2020. CT scans were analyzed using AW Server 3.2. Measurement analysis showed that the diameters of the tracheobronchial tree, the length of the trachea and left main bronchus were significantly larger in men compared to women (p<0.05 all). The smallest tracheal upper diameter was 15.25 IQR 11.8-18.8 mm vs. 17.95 13.55-20.05 mm in septic and nonseptic patients, respectively (p=0.028). A total of 26 patients who underwent CT scans developed nosocomial pneumonia. It was right-sided in 15, left-sided in 6 and bilateral in 5 patients, and correlated significantly with the left main bronchus length (ρ=0.515, p=0.007). No correlation was observed between tracheobronchial measurements and length of ICU treatment, number of hours spent on mechanical ventilation, or survival. A larger study could provide better data on the importance of tracheobronchial tree measurements in ICU patients.
Scapula fractures are very rare, resulting from high-energy trauma and are mostly associated with other fractures of the locomotor system and injuries to the head, chest or abdominal organs. Most ...often, they are treated conservatively and the indications for surgical treatment are not yet clearly agreed. One of the conditions requiring surgical treatment is a scapula fracture with fragment migration into the thoracic cavity. In this paper, we are presenting an extremely rare, isolated scapula fracture, without injury to other parts of the locomotor system, with an intrathoracic fragment migration that was treated conservatively with an excellent functional outcome.
The incidence of breast cancer in women is on the rise, but the survival rate has increased due to the progress of medicine, especially if the disease is detected early. One of the imperatives is the ...patient’s quality of life after treatment. Inadequately treated acute postoperative pain leads to a worse treatment outcome and the development of chronic pain. The incidence of chronic pain after surgical treatment of breast cancer is high and negatively affects the quality of life of patients in the long term. Serratus anterior plane block (SAPB) is a relatively new ultrasound-guided regional analgesia technique. SAPB represents an alternative to an epidural, and to paravertebral and intercostal blocks. This review aims to describe serratus anterior plane block for breast surgery and emphasize their short- and long-term benefit. For this review, we searched MEDLINE in November 2022 to identify metanalyses, randomized controlled trial systemic reviews, and reviews published in the last five years. The search for metanalyses yielded 4 results; 12 results were found for randomized controlled trials; 5 results for reviews; and 4 results for systematic reviews. When employing SAPB in patients after mastectomy, good analgesia is achieved in the early postoperative period and the incidence of chronic pain is reduced, thus improving quality of life.
Lumbar radicular pain is a major public health, social and economic problem and is often the cause of professional disability. The aim of this study was to compare pain intensity, disability and ...neuropatic pain depending on the method of treatment (epidural steroid injection or percutaneous laser disc decompression) in the treatment of lumbar radicular pain caused by intervertebral disc herniation with or without discoradicular contact. Data were collected from 28 patients at 3 measurement points (before the procedure and at examinations on the 15th and 30th day after the procedure) using the Numeric Rating Scale (NRS), Oswestry Disabilitiy Indeks (ODI) and Pain Detect. The reduction of the pain after the procedure was statistically significant only in the group of patients with discoradicular contact in whom PLDD was performed (P=0.04). From the obtained results, it can be concluded that percutaneous laser disc decompression (PLDD) led to a greater reduction in disability (P=0.009) in patients with discorradicular contact, whereas lumbar transforaminal epidural steroid injection (ESI TF) led to greater reduction in patients without discorradicular contact (P=0.02). The results indicate that there was a significant (P=0.01) reduction in neuropathic pain in patients without discorradicular contact who were treated with ESI TF and in patients with discoradicular contact who were treated with PLDD (P=0.04).
Patients after major surgery are at high risk of developing sepsis, which is accompanied by elevated serum levels of C-reactive protein (CRP) and procalcitonin (PCT). This study aimed to examine the ...differences in serum biomarker levels concerning the causative agent of sepsis in surgical patients.
A retrospective study was carried out in the surgical intensive care unit (ICU) and included 81 septic patients admitted from January 2019 to May 2022, who had positive blood cultures (BC). Serum levels of PCT, CRP, white blood cells (WBC) and platelet counts were recorded on the day of the positive BC and over the following 3 days.
Patients with gram(-) sepsis had significantly higher PCT levels, and lower platelet count compared to patients with gram(+) sepsis. High PCT and low platelets levels in all measurements were a significant predictor of gram(-) isolate with the highest predictive value on the third day after BC sampling, with AUROC 0.821 (95% CI: 0.692-0.950), P = 0.001, and AUROC 0.676 (95% CI: 0.541-0.811), P = 0.02, respectively. In multivariate logistic regression, platelets the day after BC sampling and PCT on the third day made a significant contribution in distinguishing gam(+) from gram(-) BC. Age and high serum CRP levels were significant predictors of poor outcomes.
PCT and platelets may be useful biomarkers for predicting the causative agent of sepsis in surgical patients.
Spinal and epidural blocks are common practice in anesthesia and are usually used for various surgical or endoscopic procedures. Correct identification and puncture of the epidural or subarachnoid ...space determine the success or failure of the technique. Multiple attempts and difficult access to the epidural or subarachnoid space is a frequent problem in operating theaters and may be hazardous due to a number of possible acute or long-term complications. In addition, multiple punctures are associated with increased pain and patient discomfort. The aim of this study was to determine the factors associated with a difficult spinal or epidural block, dependent on the patient (age, gender, height, weight, body mass index, and quality of anatomical landmarks), the technique (type of blockade, needle gauge, and patient positioning), and the provider (level of experience). The study was conducted at the Department of Anesthesiology, Resuscitation, and Intensive Care Unit of University Hospital Osijek (Osijek, Croatia) and it included 316 patients who underwent a range of different surgical procedures in neuraxial blocks. There were 219 cases of first puncture success, while the overall success of neuraxial blocks was 97.5%. Five patients (1.6%) were submitted to the alternative technique, ie, general anesthesia. In three patients (0.9%), neuraxial block was partial so they required supplementation of intravenous anesthetics and analgesics. Furthermore, it was found that first puncture success was associated with younger age (P=0.007), lower weight (P=0.032), and body mass index (P=0.020). Spine deformity (P=0.015), poor identification of interspinous space (P=0.005), recumbent patient position during the puncture (P=0.001), and use of a paramedian approach were associated with first puncture failure. Adequate preoperative prediction of difficulties can help to reduce the incidence of multiple attempts, rendering the technique more acceptable and less risky to the patient, and consequently leading to improvement of medical care quality. The attending anesthesiologist should consider an alternative technique (general anesthesia or peripheral nerve block) for a patient if certain difficulties can be predicted.
Sindrom kratkog crijeva očituje se malapsorpcijom koja je posljedica opsežne resekcije crijeva. Duljina crijeva preostaloga nakon kirurške resekcije smatra se glavnom odrednicom ishoda u tih ...bolesnika. Liječenje sindroma složeno je i nalaže multidisciplinarni pristup radi smanjenja morbiditeta i mortaliteta. Ovaj prikaz opisuje 60-godišnju bolesnicu koja je podvrgnuta multiplim resekcijama crijeva, što je rezultiralo preostalim tankim crijevom duljine 30 cm postduodenalno i terminalnom jejunostomom. Njezin boravak u jedinici intenzivnog liječenja zakomplicirao se zbog razvoja respiratornog zatajenja, bilateralne pneumonije i sepse. Pacijentica je mehanički ventilirana i liječena antimikrobnim lijekovima u skladu s rezultatima mikrobioloških pretraga i antibiogramom. Inicijalno je započeta potpuna parenteralna prehrana, dok se enteralna prehrana uvodila postupno. U liječenju bolesnice sudjelovao je multidisciplinarni tim sastavljen od anesteziologa, kirurga i gastroenterologa. Nakon četiri mjeseca bolničkog liječenja pacijentica je otpuštena kući opremljena tuneliranim središnjim venskim kateterom, a parenteralna je prehrana nastavljena u kućnim uvjetima u kombinaciji s peroralnim hranjenjem.
Kontinuirane metode bubrežnoga nadomjesnog liječenja posljednjih godina imaju sve veću ulogu pri zbrinjavanju bolesnika u jedinicama intenzivnog liječenja. Prednosti koje one pružaju u odnosu prema
...konvencionalnim, intermitentnim metodama pogoduju kritično oboljelima, zbog čega je ova metoda vrlo privlačna pri izboru terapijskog pristupa u jedinicama intenzivnog liječenja. Primjer je klinički prikaz dotad zdravoga četrdesetšestogodišnjeg muškarca koji je primljen u jedinicu intenzivnog liječenja zbog iznenadno nastalog poremećaja stanja svijesti, respiratorne insuficijencije, cirkulacijske nestabilnosti, rabdomiolize, anurije i akutnoga bubrežnog oštećenja nepoznatog uzroka. Bolesnik je mehanički ventiliran, volumno resuscitiran,
nalažući cirkulacijsku potporu vazopresorima. Unatoč inicijalno poduzetim mjerama intenzivnog liječenja nije došlo do oporavka diureze i hemodinamske stabilizacije uz daljnje pogoršanje stanja. Zbog perzistirajuće hiperkalemije opasne za život, metaboličke acidoze, uremije i rabdomiolize započeti su kontinuirano bubrežno nadomjesno
liječenje (engl. Continuous renal replacement therapy – CRRT), uz istodobno pružanje potpore narušenim organskim sustavima, i traganje za mogućim uzrokom prezentirane kliničke slike. Nakon tjedan dana kontinuirane potpore narušenoj bubrežnoj funkciji došlo je do oporavka stanja svijesti, hemodinamske stabilizacije, odvajanja od strojne ventilacije i oporavka diureze uz normalizaciju bubrežne funkcije. Ciljanom toksikološkom analizom urina potvrđeno je da su anabolički steroidi koje je bolesnik uzimao mogući uzrok rabdomiolize i bubrežnog oštećenja. Bolesnik je desetog dana otpušten iz jedinice intenzivnog liječenja u dobrom općem stanju i uredne bubrežne funkcije. Kontinuirane metode bubrežnoga nadomjesnog liječenja učinkovit su način zbrinjavanja akutnoga bubrežnog oštećenja u kritično oboljelih zbog nastaloga multiorganskog zatajenja različite etiogeneze.
Liječenje bolesnika koji pate od kronične boli bilo kojeg uzroka vrlo je zahtjevno i zahtijeva više modalitetni pristup analgeticima, nefarmakološkim metodama (fi zikalna terapija i akupunktura), ...injekcijama lokalnog anestetika i kortikosteroida unutar zglobnih prostora ili u okolinu živaca, a svaki dio ovog pristupa nosi određeni rizik povezan s nuspojavama i komplikacijama. Oralni protuupalni lijekovi pomažu smanjiti bol i upalu, no u određenim skupinama bolesnika su kontraindicirani ili nose veći rizik od nuspojava i komplikacija. Opioidni analgetici mogu biti teško podnošljivi, zbog mučnine ili, u težim slučajevima, povraćanja i opstipacije te bolesnici nerijetko odustaju od tih analgetika. Koanalgetici (antidepresivi i antikonvulzivi) su također lijekovi sa značajnim nuspojavama i većina ih bolesnika teško podnosi i nerado uzima. Nefarmakološke metode liječenja kronične boli su uglavnom vezane uz minimalne ili nikakve komplikacije, no ograničenog su analgetskog učinka. Injekcije lokalnog anestetika i kortikosteroida u zglobne prostore ili epiduralno nose također određene rizike od komplikacija. RF (radiofrekvencijska denervacija, neurotomija, ablacija) u literaturi se opisuje kao minimalno invazivni postupak kojim se u svrhu prekida bolnog signala u mozak na živčanom tkivu stvara toplinska lezija. RF najčešće primjenjujemo u sljedećim kroničnim bolnim stanjima: neuralgija trigeminalnog živca, bolovi u kralježnici uzrokovani degenerativnim upalnim promjenama fasetnih zglobova te artroza zgloba kuka i koljena. Tijekom ovog postupka, kao i tijekom svake druge medicinske intervencije, moguće su komplikacije koje su u literaturi vrlo rijetko opisane. U ovom članku donosimo pregled literature i naša iskustva vezana uz komplikacije RF živaca za najčešće bolne sindrome.
- This study aimed to investigate the impact of posture and anesthesia techniques on blood pressure changes, heart rate and regional cerebral oxygen saturation during shoulder arthroscopy in the ...beach chair position (BCP). Sixty patients were included in this prospective cohort study: 30 patients mechanically ventilated and subjected to general anesthesia (GA) and 30 patients subjected to interscalene block (ISB) without mechanical ventilation. Noninvasive blood pressure, heart rate (HR), peripheral blood oxygen saturation and regional oxygen saturation of the brain were measured in twelve predefined points during perioperative period. The GA group patients had significantly lower mean arterial pressure and heart rate values compared to patients in ISB group during BCP (p<0.001). There was a significant difference in regional cerebral saturation between the groups measured only in points of induction and emergence from anesthesia in favor of GA group when receiving 100% oxygen (p<0.001). Changes in the mean arterial pressure and regional cerebral oxygen saturation for both brain hemispheres correlated only at the 10
minute after setting up BCP in GA patients (right, p=0.004 and left, p=0.003). This correlation did not exist in the ISB group patients at any of the points measured. Cerebral desaturation events recorded in both groups were not statistically significantly different. Results of this study demonstrated that GA preserved regional cerebral oxygenation in a safe range during BCP despite changes in the arterial blood pressure and heart rate in comparison to ISB.
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