Cilj ovoga preglednog članka je objasniti anesteziološki pristup bolesnicima s opstrukcijskom apnejom tijekom spavanja (engl. Obstructive Sleep Apnea, OSA), prikazati rezultate najnovijih ...istraživanja i osvrnuti se na nedavno objavljene smjernice i preporuke. OSA je najčešći poremećaj disanja vezan uz spavanje. Smatra se da je OSA sustavna bolest s više raznih fenotipova i patofi zioloških mehanizama. Dokazano je da bolesnici s OSA-om imaju znakovito povećanu incidenciju perioperacijskih komplikacija, a osobito onih vezanih za održavanje dišnoga puta. Bolesnici s OSA-om osjetljivi su na konvencionalne anestetike i sedative, osobito na opioide. Stoga, u ovih bolesnika kad god je moguće treba primijeniti lokoregionalne tehnike. Među kirurškim bolesnicima izrazito je visoka prevalencija OSA-e, a veliki broj bolesnika je prijeoperacijski nedijagnosticiran. Defi nitivna dijagnoza OSA-e moguća je jedino polisomnografi jom, koja nije uvijek dostupna. Stoga se danas sve više preporuča uporaba raznih validiranih prijeoperacijskih testova i upitnika (STOP, STOP-BANG, Berlin, ASA, P-SAP) koji zadovoljavajuće koreliraju s poslijeoperacijskim ishodima i pomažu u prijeoperacijskoj stratifi kaciji rizika. Veliki napredak su i smjernice Američkog udruženja anesteziologa iz 2014. godine, te preporuke Američkog udruženja za anesteziju i medicinu spavanja iz 2016. godine. Novije smjernice doimaju se praktične, jer svrstavaju bolesnike u tri skupine: 1) bolesnici s dijagnosticiranom OSA-om, koji se pridržavaju liječenja pozitivnim tlakom (engl. Continuous Positive Airways Pressure, CPAP), 2) bolesnici s dijagnosticiranom OSA-om, koji odbijaju ili se slabo pridržavaju liječenja CPAP-om, te 3) bolesnici pod sumnjom na OSA-u. Te smjernice po prvi puta navode i defi niraju termin nekontrolirane sustavne bolesti. Nadalje, taj novi strukturirani pristup daje jasne preporuke uz već nazočne smjernice ASA iz 2014. godine.
Migratory foreign body appeared to be bird feather, caused peritonsillar and periparotid abscess in a nine-month-old infant. Patient presented painful, tender and fluctuating red neck mass on the ...left neck region II, and refusal of oral intake, with no fever. Azithromycin was introduced four days before presentation for suspected urinary tract infection. ENT examination revealed left peritonsillar abscess; ultrasound confirmed periparotid abscess, MSCT verified both diagnoses. Under general anaesthesia, we performed abscess incision, after pus drainage, small foreign body spontaneously came through the wound. After washing it with saline, it appeared like a bird feather. Subsequently, peritonsillar abscess was incised and drained. After 24-hour postoperative care on pediatric intensive care unit, the patient continued three-day parenteral antibiotic treatment on the otolaryngology department; it was discharged with a recommendation to continue seven days of oral antibiotic therapy. Suggested mechanism was ingestion of bird feather from stuffed bedding, that got trapped in the tonsillar crypt. Afterwards, it started to migrate through the neck tissue. Households with children younger than three years should not have feather stuffed clothes or beddings.
Cilj je ovog rada prikaz bolesnika s iznimno opsežnim opeklinama svih dijelova tijela. Muškarac srednjih godina 12-ak sati prije početka bolničkog liječenja u KBC-u Split pokušao je suicid paljenjem ...plinske boce u zatvorenom prostoru, oko 150 kilometara od ustanove gdje je započeto liječenje. Eksplozija i požar kojima je pacijent bio izložen uzrokovali su opekline visokog stupnja na velikoj tjelesnoj površini. U trenutku prijma na bolničko liječenje pacijent je bio ekstremno agresivan i nesuradljiv. Važno je naglasiti da pacijent u trenutku prijma na bolničko liječenje nije imao uspostavljen venski put. U bolnicu je primljen sa znatnom odgodom (12 sati +/- 1 sat), koja je produbila dehidraciju i pogoršala njegovo, već ionako životno ugroženo stanje. Dubina opeklina
procijenjena je na stupnjeve II. b i III., a zahvaćale su 70% ukupne površine tijela (engl. Body surface area – BSA). Prvi cilj prije volumne nadoknade bila je uspostava odgovarajućega venskog puta, koji pacijent u trenutku prijma u bolnicu nije imao. Zbog agitiranosti i agresivnosti intramuskularno se injicirala kombinacija midazolama, ketamina
i atropina, a središnji venski pristup uspostavio se tek kad je pacijent bio anesteziran. Obilna nadoknada kristaloidima za vrijeme inicijalnoga trosatnog zbrinjavanja privremeno je stabilizirala bolesnika, a agresivna
nadoknada kristaloidima i koloidima nastavljena je u jedinici intenzivnog liječenja. Potrebe za kristaloidima u prva 24 sata izračunane su s pomoću Parklandske formule i iznosile su 25.200 mL kristaloida. Tijekom liječenja pacijent je šest puta podvrgnut kirurškim zahvatima uz svakodnevna previjanja u općoj anesteziji. Boravak se zakomplicirao
zbog infekcije multirezistentnim Acinetobacter baumannii. Zaključno, Parklandska formula ostaje okosnica volumne nadoknade pacijenata s opeklinama II. i III. stupnja. Odgoda liječenja, prisutna u ovom slučaju, rezultirala je enormnom dehidracijom i gubitkom intravaskularnog volumena sa svim patofiziološkim poremećajima pridruženima takvom stanju. Zbrinjavanje pacijenta bilo je dodatno otežano zbog njegove agresivnosti pri prijmu, nedostatka venskog puta i nemogućnosti započinjanja liječenja odmah ili vrlo brzo nakon nastalih opeklina.
Objective: The aim of the study was to investigate the effects of using low-dose mannitol (0.3 g kg
−1
) on the pulsatility index (PI) and minimum diastolic blood flow velocity (FV-min) of the middle ...cerebral artery in a traumatic brain injury (TBI).
Methods: Low-dose mannitol (0.3 g kg
−1
) was administered to a group of 20 patients with a TBI. Transcranial Doppler (TCD) ultrasonography was used to monitor the PI and FV-min. The study included patients with a diffuse traumatic brain injury and Glasgow coma score < 8. The initial TCD ultrasonography values were pathological (PI > 1.4 and FV-min < 20 cm s
−1
). TCD ultrasonography examinations were carried out before mannitol administration, immediately after administration and 1, 2 and 3 hours after the administration of mannitol.
Results: A one-way analysis of variance revealed significant changes in the PI (F = 8.392; p < 0.001) and FV-min (F = 8.291; p = 0.001) after the use of mannitol.
Conclusions: Low-dose mannitol administration appears to be efficacious for improving the indicators of disturbed circulation in a TBI (FV-min increase, PI decrease). The maximum decrease in the PI was recorded 1 hour after the administration of mannitol and was 10.9% of the initial value. The maximum increase in the FV-min was recorded 1 hour after administration and was 29.7% of the initial value. These changes were significant ∼ 2 hours later.
To clarify the influence of microvessel density (MVD), lymphangiogenesis (LVD), and vascular invasion on prognosis in lymph node-negative colon cancer.
We performed immunohistochemical analysis from ...152 Duke's B colon carcinomas, CD34 and LYVE-1 antibodies. Carcinomas were graded as low or high grade. χ2 test was used to examine their relationships and correlations with clinicopathological parameters. Survival time was analyzed and the differences between groups were assessed.
A statistically significantly correlation was found between increasing MVD with age >60 years, tumor size >4cm, and poor tumor differentiation (χ2=40.018, p<0.001). The increase in MVD was associated with shorter DFS (p<0.001) and shorter OS in patients with colon cancer (p<0.001). LVD was statistically significantly associated with increasing the number of newly created blood vessels (χ2=96.6, p<0.001), low degree of tumor differentiation (χ2=96.6, p<0.001), and vascular invasion (χ2=51.8, p<0.001) in colon cancer. Log rank analysis showed that positive staining for MVD and LVD, high histological grade, vascular invasion, male gender, and age >60 years were connected with shorter survival of patients with Dukes B colon cancer 45 vs. 100 months (p=0.016 to <0.001).
Positive expression MVD and LVD was significantly correlation with survival time and with high tumor grade and vascular invasion in patients with Dukes B colon cancer. The correlation of MVD and LVD with vascular invasion in Dukes B colon cancer indicates the need for further confirmation as a possible predictive marker.
A 62-year-old male died of colchicine poisoning after accidental ingestion of Colchicum autumnale (meadow saffron). He ate a salad of plant with green leaves regarded as wild garlic (
Allium ...ursinum). A few hours later he developed symptoms of gastroenteritis and was admitted to hospital. In spite of gastric lavage, activated charcoal and supportive measures, multi-organ system failure developed over the next two days. Laboratory analysis showed highly elevated blood concentrations of hepatic enzymes, creatine kinase, lactate dehydrogenase and blood urea nitrogen, as well as leukocytopenia and thrombocytopenia. Mechanical ventilation, dopamine, noradrenaline, crystalloid solutions and fresh frozen plasma were applied but despite treatment the patient died five days after the ingestion. Post-mortem examination revealed hepatic centrilobular necrosis, nephrotoxic acute tubular necrosis, petechial bleeding in fatty tissue, blunt and shortened intestinal villi and cerebral toxic edema. Botanical identification of incriminated plant gave
Colchicum autumnale which confirmed colchicine poisoning. Although the accidental ingestion of
Colchicum autumnale is rare and to our knowledge only five such cases have been described in detail, this is the second fatal case in Croatia described in the last 3 years.
The aim of this research is to design a better and more efficient process of sale and delivery of a specific product in a sales company in Split, Croatia. For this purpose, a model based on the ...current performance of this core process (AS-IS model), will be shown. The goal is to establish such a business process where there would be no queuing and where the resources are used efficiently. Eliminating these problems would then reduce operational costs. The optimization and simulation of the process seeked to find an optimal (TO-BE) solution. The processes are modeled in ARIS Business Arhitect 7.0 while optimization is done with OptQuest from simulation tool Arena 7.0.
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