Velopharyngeal insufficiency is a disorder where the soft palate directs the air through the nose. It is often present in patients with previous cleft or short palate, but also in many other ...conditions. Symptoms are primarily to be found in speech, with very distinct nasal sound. After clinical evaluation and nasal endoscopy, surgery is considered. Several surgical techniques are in use, with posterior pharyngeal flap pharyngoplasty being most widely used. This method leaves the base of the posterior pharyngeal flap attached to the posterior pharyngeal wall, with two lateral ports on each side of the flap. Permanent nasopharyngeal obstruction is a very challenging pathology for anesthesiologists in case of mandatory nasal intubation since it is a relative contraindication for nasal intubation. Patients with previous palatoplasty will regularly appear in our routine anesthetic practice, in all surgical segments. The high risk of damage to the flap with possible bleeding can put the anesthesiologist in a very unpleasant situation if not aware of the permanent effect of this surgery. During preanesthetic assessment, if there is information on a previous pharyngoplasty, one should consider alternative options for nasotracheal intubation. All nasal insertion procedures must be either avoided or carried out with great caution, under fiberoptic visual control.
SCIWOCTET is a cervical spine injury (CSI) with objective signs of myelopathy, due to trauma, without evidence of ligament injury or bone fractures on x-ray and computed tomography (CT) images. It is ...rare, found in about 3% of patients with CSI. Perioperative manipulation of these patients may cause secondary spinal cord injury. The challenge for the anesthesiologist is to manage an airway with as little movement of the patient's head and neck as possible. A patient is presented after a fall from a motorbike. At hospital admission, he had neurological deficit in the innervation area of the cervical spinal cord. Multi-slice CT of the head and cervical spine was without signs of acute bone trauma. Magnetic resonance imaging was performed and the diagnosis met the criteria defining SCIWOCTET. Elective cervical spine surgery under general anesthesia was performed, the patient was intubated with a rigid bronchoscope using manual in-line immobilization. The selection of instruments and procedures is emphasized. Other procedures, techniques and instruments that can be used for airway management and their influence on the movement of the patient's head and neck are listed. It is concluded that rigid bronchoscopy with the application of manual in-line immobilization is suitable for emergency and elective intubation of patients with cervical spine pathology.
Uspostaviti i održati dišni put jedna je od najvažnijih interesnih točaka anesteziologa, no još u dalekoj prošlosti već su i „obični ljudi“ shvatili koliko je važno očuvati dišni put. Tako je krenuo ...dug i fascinantan put tijekom kojega se su se progresivno razvijala pomagala i tehnike namijenjene očuvanju dišnog puta, kao i svijest o važnosti njegovog očuvanja. Od prvih traheotomija tisuću godina prije Krista, preko direktne laringoskopije i ventilacije
bolesnika uz pomoć modernih anestezioloških aparata, došli smo do ere raznih videopomagala: stileta, rigidnih i fleksibilnih bronhoskopa, videolaringoskopa i tako dalje. Veliku ulogu imalo je osvještavanje problema, brojne analize grešaka koje smo kao struka nehotice ostavljali iza sebe tijekom silnih pokušaja i promašaja u nastojanju da učinimo najbolje što možemo za bolesnika. Zahvaljujući tomu i enormnom tehnološkom napretku u zadnjih dvjesto godina, možemo reći da je došlo do revolucije u održavanju dišnog puta. Izazovi u prošlosti naučili su nas mnogo. Međutim, tijekom još uvijek aktualne pandemije COVID-19, opet smo se susreli s novim izazovima dišnog puta, ali iako nitko nije mogao ni približno zamisliti što nas čeka snašli smo se. Za razliku od uobičajenog načina na koji inače radimo u operacijskim dvoranama i jedinicama intenzivne skrbi, vodeći računa o sigurnosti bolesnikova dišnog puta ovaj smo put morali paziti i na to da zaštitimo svoj.
Pretilost je često povezana s komorbiditetnim stanjima (opstruktivna apneja u snu, hipertenzija, šećerna bolest tipa 2…). Anestezija temeljena na opioidima povećava rizik od kritičnih respiracijskih ...događaja tijekom oporavka od kirurškog zahvata, pogoršava učestalost i težinu postoperativne mučnine i povraćanja te dovodi do hiperalgezije. Zbog navedenog cilj je izbjeći ili značajno smanjiti primjenu opioida kod kirurškog zahvata na morbidno pretilim bolesnicima. Ovo daje prednost kombinaciji opće i regionalne anestezije. Prikazana su dva slučaja uzdužne resekcije želuca kod morbidno pretilih bolesnika uz anesteziju bez primjene opioida. Primijenjen je obostrani torakalni paravertebralni blok s levobupivakainom i deksametazonom postavljen uz pomoć ultrazvuka na razini Th 4 i Th 7. U operacijskoj dvorani napravljena je indukcija propofolom i esmeronom, a anestezija je održavana istim lijekovima. Na početku operacije pacijentima je za analgeziju dan metamizolnatrij hidrat, a na kraju operacije paracetamol. Ekstubirani su u jedinici za prijeanestezijski i postanestezijski nadzor. Nakon buđenja pacijenti su bili bez bolova, bez mučnine, imali su osjećaj zatezanja šavova i drena kod pomicanja. Na odjelu su dobili nesteroidni antireumatik, a tegobe koje su imali nisu bile posljedica kirurgije niti anestezije. Tijekom razdoblja praćenja (do kirurške kontrole nakon četiri tjedna) pacijenti nisu osjećali bolove vezano uz operaciju. Provedena je anestezija bez opioida, postignuta je odgovarajuća kontrola boli uz brzi oporavak aktivnosti crijeva i ranu mobilnost pacijenata.
Pedijatrijska je populacija po mnogo čemu specifična. Iako na prvi pogled djeca djeluju kao umanjena verzija odraslih, oni se uvelike razlikuju u anatomiji, kao i fiziologiji. Kada govorimo o ...pedijatrijskoj anesteziji moramo imati na umu sve anatomske, fiziološke, farmakodinamske i farmakokinetičke razlike jer će one uvelike utjecati na sve aspekte anestezije – od uvoda, preko osiguravanja i održavanja dišnog puta, do konačnog buđenja iz anestezije i ekstubacije. Kada se fiziološkim i anatomskim varijancama u pedijatrijskoj populaciji pridruže još stanja ili sindromi koji mogu dodatno otežati uspostavu dišnog puta ili ventilaciju, suočavamo se s problemom koji treba ozbiljno shvatiti i trenutno reagirati. U nebrojeno je mnogo istraživanja odavno dokazano da hipoventilacija s posljedičnom hipoksijom i hiperkarbijom može iznimno brzo rezultirati kobnom respiratornom insuficijencijom koju, ako se promptno ne reagira, u stopu može pratiti kardijalni arest. Uz pregled literature prikazujemo i primjer četveromjesečnog djeteta kod kojega je bila planirana operacija rascjepa usne u općoj endotrahealnoj anesteziji. Nakon uvoda u anesteziju, uz otežani prikaz laringealnih struktura direktnom laringoskopijom, uz pomoć videolaringoskopa i dobru vizualizaciju glotisa pokušana je intubacija koja nije bila izvediva zbog nemogućnosti plasiranja
tubusa kroz preusku rimu glotidis. Operativni zahvat je odgođen za mjesec dana. U drugom pokušaju dijete je uspješno intubirano i operirano, bez ikakvih komplikacija. Zbog anatomskih i fizioloških varijacija vezanih za životnu dob svakog pojedinog djeteta, zatim različitih vrsta i opsega rascjepa, potreban je individualizirani pristup. Važno je prepoznati i situacije u kojima ne treba inzistirati na kirurškoj ili anesteziološkoj intervenciji, već odustati i malo pričekati kako bi se anatomski odnosi uslijed somatskog rasta okrenuli u djetetovu korist.
Uvod i cilj: Pojam jednodnevne kirurgije datira iz početka 20. stoljeća. James Nicoll objavio je 1909. godine u časopisu British Medical Journal rezultate kod 8.988 djece operirane po principu ...jednodnevne kirurgije. Prema Međunarodnom udruženju za jednodnevnu kirurgiju (IAAS), pacijent u jednodnevnoj kirurgiji definiran je planiranim prijamom u zdravstvenu ustanovu s ciljem dijagnostičkog i/ili operativnog zahvata, gdje se po zahvatu
očekuje brz oporavak te ne postoji potreba za hospitalizacijom – otpušta se kući isti dan. Razvoj kirurških metoda, anestezioloških tehnika i metoda analgezije doprinosi eksponencijalnom porastu broja pacijenata zbrinutih po principu jednodnevne kirurgije. Metode: U radu prikazujemo pregled literature putem baze podataka MEDLINE koristeći ključne pojmove. Cilj je prikaz osnovnog koncepta uspjeha jednodnevne kirurgije: kritičan preoperativni probir, odabir najbolje anesteziološke i kirurške tehnike, otpust prema važećim kriterijima. Rezultati: Izbor pacijenata s obzirom na dob, težinu, komorbiditete, ASA status te socijalni aspekt ako je sagledan individualno i praćen zahvatom koji je definiranim vremenskim trajanjem i niskom incidencijom postoperativnih komplikacija uz korištenje optimalnih anestezioloških tehnika i lijekova rezultira dobrim postoperativnim uspjehom uz ekonomske uštede. Zaključak: Prednosti jednodnevne kirurgije jasne su i dokazane: usmjerena je na pacijenta, nosi niži rizik
postoperativnih komplikacija i hospitalnih infekcija, ekonomična je.
There is a controversy in results about influence of surgery on pulmonary function in idiopathic scoliosis. The aim of the study was to study pulmonary function in severe thoracic idiopathic ...scoliosis and to detect changes in pulmonary function after the three-dimensional anterior surgical correction in severe thoracic scoliosis. 91 patients at the age of 16 +/- 5.1 yrs underwent surgery in order to make a correction of scoliotic deformity. All the curves were greater than 70 degrees (86 +/- 5.1). Group I consisted of 60 patients with scoliotic curves between 70 degrees and 100 degrees, while group II consisted of 31 patients with curves greater than 100 degrees. All the patients were operated by anterior instrumentation and the average correction was 74% +/- 15 for group I, and 71% +/- 18 for group II. Vital capacity (VC) and forced expiratory volume in the first second (FEV1) in group I remained unchanged. In group II, VC improved for 11%, while forced expiratory volume (FEV) improved for 13.6%. Our conclusion is that there is a significant correlation between the percentage of achieved correction and pulmonary function.
The relationship between trunk and spine deformity has yet not been well defined. The purpose of this study was to identify the relationship between clinical (contourometric) and radiographic methods ...of scoliotic deformity evaluation. Our second objective was to create mathematical formulas for calculating radiographic parameters based on defined correlations of multiple parameters. We did a study of 136 preoperatively analysed patients with idiopathic scoliosis. Altogether, 189 lateral curvatures were assessed. Based on Lenke's classification, curves were divided into three groups: a thoracic, a thoracolumbar and a lumbar curve group. Each group was analyzed separately to determine relationships between clinical contourometric (scoliometer value, humpometer values) and radiographic measurement (apical vertebral rotation (AVR) according to Drerup). On the grounds of statistically significant correlation coefficients of most clinical parameters and Drerup rotation we found good relationships between trunk and spine deformity. Using the best correlated clinical parameters and multiple regression statistical analysis we created mathematical formulas for prediction of scoliotic AVR in higher degree curves.
That political philosophy and political theory as such, appeared in Classical Greece and not before or elsewhere, is a hard and indisputable fact of modern scholarship. But to acknowledge and ...perceive a fact is one thing, to explain it quite another. Why were the ancestors of modern scientific and philosophical disciplines created in Ancient Greece and not somewhere else is a difficult question that was tackled by many capable researchers from various fields, in the last two centuries. Philosophers, historians, archaeologists, philologists and students of politics, to name but a few of these fields, approached the problem from different angles, and gave many answers to it, both valid and unsound. Many of the more simplistic explanations, especially those that seek to connect the “Greek miracle” with a single factor, are now considered obsolete and are no longer taken seriously. But this difficult and intriguing problem remains.
The question can be rephrased in several different ways, some of which could potentially open new approaches to the problem. For example, we could ask why didn’t the cultures of the Ancient Near East, with their grand achievements in many fields of creativity, produce science, philosophy or political theory, in the ways the Greeks did. The answer can be obtained by a deeper analysis of social and cultural conditions in Ancient Mesopotamia and Egypt, and other ancient Eastern cultures. Once we understand that these are hierarchical and bureaucratic societies, dominated by the two pivotal institutions - the ruler’s court and the temple - where the world view was shaped predominantly by the religious and mythical concepts, and where the individuality of any single person (apart from the king himself and his immediate surroundings) was subordinated to a collective mentality, identity and interests, the question seems much easier to answer. But what about the Ancient Greece?
Velopharyngeal insufficiency is a disorder where the soft palate directs the air through the nose. It is often present in patients with previous cleft or short palate, but also in many other ...conditions. Symptoms are primarily to be found in speech, with very distinct nasal sound. After clinical evaluation and nasal endoscopy, surgery is considered. Several surgical techniques are in use, with posterior pharyngeal flap pharyngoplasty being most widely used. This method leaves the base of the posterior pharyngeal flap attached to the posterior pharyngeal wall, with two lateral ports on each side of the flap. Permanent nasopharyngeal obstruction is a very challenging pathology for anesthesiologists in case of mandatory nasal intubation since it is a relative contraindication for nasal intubation. Patients with previous palatoplasty will regularly appear in our routine anesthetic practice, in all surgical segments. The high risk of damage to the flap with possible bleeding can put the anesthesiologist in a very unpleasant situation if not aware of the permanent effect of this surgery. During preanesthetic assessment, if there is information on a previous pharyngoplasty, one should consider alternative options for nasotracheal intubation. All nasal insertion procedures must be either avoided or carried out with great caution, under fiberoptic visual control. Key words: Velopharyngeal insufficiency; Iatrogenic nasopharyngeal obstruction; Nasal intubation; Airway Velofaringealna insufficijencija stanje je kod kojega meko nepce zrak usmjerava kroz nos umjesto na usta. Cesta je kod bolesnika koji su imali rascjep nepca ili imaju kratko nepce, ali javlja se i u drugim bolestima. Simptomi su primarno govorne prirode, s vrlo izrazenim nazalnim prizvukom. Nakon klinickog pregleda i endoskopskog pregleda nazofarinksa odlucuje se o daljnjoj kirurskoj intervenciji. Danas je nekoliko kirurskih tehnika u opticaju, no najcesce se rabi faringoplastika s odizanjem sluznicno-misicnog reznja sa straznjega zida farinksa. Nakon ovog zahvata baza reznja ostaje pricvrscena za straznji zid farinksa, sa samo dva otvora sa svake lateralne strane reznja. Trajna opstrukcija nazofarinksa zahtjevna je patologija za anesteziologe u slucajevima koji zahtijevaju nosnu intubaciju, jer nova poslijeoperacijska anatomija predstavlja relativnu kontraindikaciju. Bolesnici kojima je ucinjena palatoplastika povremeno budu dio rutinske anestezioloske prakse u svim segmentima kirurgije. Visok rizik za ozljedu reznja uz popratno krvarenje moze anesteziologa staviti u neugodan polozaj ako nije upoznat s posljedicom koja bolesniku ostaje dozivotno nakon operacije. Kao dio anestezioloske prijeoperacijske procjene, ako znamo da je bolesniku ucinjena faringoplastika, svakako treba razmotriti alternativne nacine intubacije na nos. Svi postupci koji ukljucuju umetanje predmeta u nos treba ili izbjegavati ili raditi krajnje oprezno, uz obveznu kontrolu fiberoptickim bronhoskopom. Kljucne rijeci: Velofaringealna insufficijencija; Jatrogena opstrukcija nazofarinksa; Nosna intubacija; Disni put
