Gastric tube ulcer perforating the pericardium after subtotal esophagectomy [Perforacija ulkusa želučanog supstituta u perikard nakon subtotalne ezofagektomije]

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature

Hemodynamic collapse with cardiac arrest during a high subarachnoid block

Background: In this case report we tried to identify possible factors which could be related to developing an inappropriately high subarachnoid block and consequential hemodynamic collapse. Case report: A 59 year old female patient was predicted for a lower extremity peripheral revascularization procedure.The progressive spread of spinal block with a decrease in blood pressure and slowing of heart rate ultimately resulted in a a bradycardia which lead to cardiac arrest. Since known risk factors were inapparent and CSF volume as a possible reason for the high block was excluded, we measured the segment length from the Th12 to the L5 vertebra with an MRI scan. Values for the respective parameters of lumbar segment length, angle of inclination and de clination, lowest and highest points of the spinal canal which can be obtained from existing literature were compared to our results and we saw that the lumbar segment length and angle of inclination were not within the described ranges and that the lowest point of the spinal canal was at the cranial margin of the values described in literature. Thus we considered if the shorter lumbar segment and lowest spinal canal point at the Th7 level are responsible for the cranial distribution of the subarachnoid block. Conclusion: Lumbar segment length, AP and LL diameters of the spinal canal and the lowest spinal canal point could help us identify higher risk groups which might require a modified dose of LA in order to assure optimal care for the patient

Increase in Specific Density of Levobupivacaine and Fentanyl Solution Ensures Lower Incidence of Inadequate Block

The clinical presentation of a subarachnoid block (SAB) is dependent upon the intrathecal spread of local anesthetic (LA). Intrathecal distribution depends on the chemical and physical characteristics of LA, puncture site, technique used, patient anatomical characteristics and hydrodynamic properties of cerebrospinal fluid. We tried to determine whether a combined glucose/LA solution can render a clinically significant difference in sensory block distribution and motor block intensity.This was a controlled, randomized and double blinded study. The surgical procedures were stripping of the great or small saphenous vein and extirpation of remaining varicose veins. The study included 110 patients distributed into two groups: Hyperbaric (7.5 mg levobupivacaine (1.5 ml 0.5% Chirocaine®) + 50 mg Fentanyl (0.5 ml Fentanil®) and 1 ml 10% glucose (Pliva)) vs. Hypobaric (7.5 mg levobupivacaine (1.5 ml 0.5% Chirocaine®) + 50 mg Fentanyl (0.5 ml Fentanil®) and 1 ml 0.9% NaCl (Pliva, Zagreb)) adding to a total volume of 3.5 ml per solution. Spinal puncture was at L3-L4 level. Spinal block distribution was assessed in five minute intervals and intensity of motor block was assessed according to the modified Bromage scale. Pain was assessed with the Visual Analogue Scale. A statistically significant difference in sensory block distribution, motor block intensity and recovery time was established between hyperbaric and hypobaric solutions. By increasing the specific density of anesthetic solution, a higher sensory block, with lesser variability, a diminished influence of Body Mass Index, decreased motor block intensity and faster recovery time may be achieved

Perioperative Management with Glucose Solution and Insulin

The objective of this study was to analyze how preoperative glucose treatment influences the blood glucose level as a measured exponent of surgical stress and to establish the best postoperative replacement considering glucose solutions and insulin. This prospective clinical trial involved 208 non-diabetic patients with normal glucose tolerance, who underwent major surgical procedures and needed 24 hours ICU monitoring postoperatively. Patients were randomly given 5% glucose solution (1000 mL) one day before surgery or after overnight fasting. Group A and group B were randomized to be given 5 different kinds of postoperative replacement with cristalloids and insulin. None of the patients from group A or group B were given glucose solutions during surgical procedures. Blood glucose levels were measured 14 times from the preoperative period until 24 hours after admission to the ICU and the main outcome measure was blood glucose level. All patients had a statistically significant increase in blood glucose levels in comparison to basal levels (p<0.05) in all measurements. All data were processed with descriptive statistics, chi-square test, parametric ANOVA test and ANOVA test with repeated measure, non parametric Kruskal-Wallis test and Mann-Whitney U-test. Statistically significant change was accepted with p<0.05. Preoperative glucose infusion decreased metabolic and endocrine response only during surgery; the smallest increase of postoperative blood glucose level was noticed after administering postoperative non-glucose crystalloid solutions; there is no clinical evidence that one specific postoperative replacement is better than the other; there is no clinical evidence that postoperative use of insulin can decrease or attenuate surgical induced insulin resistance

Primjena paravertebralnog bloka za postavljanje gastrostome kod visoko rizičnih bolesnika s karcinomom jednjaka – dva prikaza slučaja

Here we present two cases of gastrostomy insertion via laparotomy in patients with malignant esophageal disease. Patients were ASA (American Society of Anesthesiologists) physical status III and IV. The patients presented as very high risk for general anesthesia, so we decided to use unilateral left sided paravertebral block (PVB) on four thoracic levels along with contralateral local infiltration at the gastrostomy insertion site. We present two cases, one of them a 57-year-old male ASA III patient scheduled for a gastrostomy procedure due to esophageal cancer with infiltration of the trachea. We also present a case of a 59-year-old male patient, ASA IV status, scheduled for the same procedure due to advanced esophageal cancer with a fistula between the left main bronchus and the esophagus and metastases in the left lung. The paravertebral space was identified with the use of an 8 Hertz (Hz) linear ultrasound probe and a nerve stimulator. Paravertebral block was successfully used for insertion of a gastrostomy, thereby enabling adequate anesthesia and perioperative analgesia without hemodynamic or respiratory complications.Prikazujemo dva slučaja postavljanja gastrostome laparotomijskim putem kod bolesnika s malignom bolesti jednjaka. Bolesnici su prema Američkom anesteziološkom društvu (American Society of Anesthesiologists, ASA) klasificirani kao ASA status III i IV. Zbog vrlo visokog rizika za primjenu opće anestezije prikazanim bolesnicima odlučili smo primijeniti prsni paravertebralni blok na četiri razine s nasuprotnom lokalnom infiltracijom mjesta postavljanja gastrostome. Prikazujemo dva slučaja; jedan je bio 57-godišnji ASA III bolesnik predviđen za postavljanje gastrostome zbog karcinoma jednjaka s infiltracijom traheje. Također prikazujemo 59-godišnjeg ASA IV bolesnika predviđenog za isti zahvat zbog uznapredovalog karcinoma jednjaka s fistulom između glavnog lijevog bronha i jednjaka uz metastaze na lijevom plućnom krilu. Paravertebralni prostor je identificiran primjenom ultrazvučne linearne sonde od 8 Hertza (Hz). Paravertebralni blok je uspješno primijenjen za postavljanje gastrostome omogućavajući time zadovoljavajuću anesteziju i perioperacijsku analgeziju bez hemodinamskih i respiracijskih komplikacija

Who is the Patient? Disclosure of Information and Consent in Anesthesia and Intensive Care (Informed Consent)

Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the prac- tice, however with the vast advances in science and technology, numerous ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hip- pocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together repre- sent the complete best interest of the patient. This is the basic goal of the »Informed Consent«. The widening of legal boundaries regarding professional liability may consequentially lead to a »defensive medicine« and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evalu- ating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief, explain all the necessary information a »reasonable« anesthesiologist would disclose to a »reasonable« patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient

Uloga paravertebralnih blokova u ambulatornoj kirurgiji: pregled literature

Ambulatory surgery often involves surgical procedures on the thorax, abdomen and limbs, which can be associated with substantial postoperative pain. The aim of this narrative review is to provide an analysis of the effectiveness of paravertebral block (PVB) alone or in combination with general anaesthesia, in this setting, with an emphasis on satisfactory postoperative analgesia in comparison to other modalities. We have conducted a search of current medical literature written in English through PubMed, Google Scholar and Ovid Medline®. Peer-reviewed professional articles, review articles, retrospective and prospective studies, case reports and case series were systematically searched for during the time period between November 2003 and February 2019. The literature used for the purpose of creating this review showed that utilisation of paravertebral block either alone or in combination with general anaesthesia, has a positive effect on satisfactory analgesia in ambulatory surgery. With a multimodal analgesic approach of PVB and other techniques of anaesthesia and analgesia there is a reduction in postoperative opioid consumption, fewer side effects, lower pain scores, decreased mortality, earlier mobilisation of patients and reduced hospital stay.Ambulatorna kirurgija uključuje kirurške zahvate na udovima, u području prsnog koša i trbuha koji su često povezani s pojavom jake perioperacijske boli. Cilj ovoga narativnog preglednog članka je preispitati učinkovitost primjene paravertebralnoga bloka (PVB) samostalno ili u kombinaciji s općom anestezijom u postizanju zadovoljavajuće perioperacijske analgezije kod ambulatorne kirurgije naspram drugih analgetskih metoda. Proveli smo istraživanje aktualne medicinske literature napisane na engleskom jeziku kroz PubMed, Google Scholar i Ovid Medline®. Recenzirani stručni članci, pregledni članci, retrospektivne i prospektivne studije, prikazi slučajeva i serije slučajeva sustavno su pretraživani u razdoblju između studenog 2003. i veljače 2019. godine. Istraživanja uključena u naš narrative review prikazala su učinkovitost primjene PVB samostalno ili u kombinaciji s općom anestezijom u postizanju zadovoljavajuće perioperacijske analgezije kod ambulatorne kirurgije. Multimodalnim analgetskim pristupom primjene kombinacije PVB s drugim tehnikama anestezije i analgezije postiže se smanjenje potrošnje opioida, manje nuspojava, niže vrijednosti procjene boli na vizualno analognoj ljestvici, smanjenje mortaliteta, brža mobilizacija bolesnika te skraćenje vremena boravka u bolnici

Haemodynamic monitoring: from invasive monitoring to personalised medicine

Kontinuirano praćenje srčanoga minutnog volumena (CO) i održavanje normovolemije primarni su ciljevi optimizacije hemodinamskog (HD) statusa svakoga kritičnog bolesnika. Za razliku od samo invazivnog nadzora i intermitentne termodilucijske procjene CO-a s pomoću plućnog arterijskog katetera, danas se puno više primjenjuju minimalno invazivne i potpuno neinvazivne metode. Minimalno invazivne metode koje se s pomoću transpulmonalne termodilucije (TD) pri procjeni CO-a služe analizom krivulje tlaka pulsa dijele se na starije, kalibrirane i novije, nekalibrirane. Dinamički parametri kao što su varijacija udarnog volumena (SVV) i varijacija pulsnog tlaka (PPV), koji se kontinuirano prate ovim metodama, puno preciznije odražavaju potrebu za ciljanom optimalnom volumnom nadoknadom (GDVT) u odnosu prema tradicionalnim, statičkim parametrima (CVP i PCWP). Suvremenije neinvazivne kontinuirane metode koje još nisu dovoljno validirane u kliničkim uvjetima jesu aplanacijska tonometrija, pletizmografija, metoda djelomičnoga ponovnog udaha parcijalnog CO2 i procjena CO-a temeljena na tranzicijskom vremenu pulsnog vala. Torakalna električna bioimpedancija i bioreaktancija koriste se slabom naizmjeničnom strujom koja prolaskom kroz prsni koš kontinuirano u sistoli prati fazne pomake napona i analizira krivulju udarnog volumena (SV). Poznato je da primjenom volumena u oko 50% kritičnih bolesnika neće doći do povećanja SV-a, stoga je važno prije primjene volumena kontinuiranim praćenjem SV-a/CO-a procijeniti hoće li biti prikladnoga HD odgovora na volumen. Danas postoji više metoda kojima se može procijeniti odgovor na volumnu nadoknadu poput mjerenja varijacije dijametra donje i gornje šuplje vene, okluzijskog testa na kraju ekspirija, testa respiratorne sistoličke varijacije, SVV-a i PPV-a. Pasivno podizanje nogu (PLR) ima najveću prediktivnu vrijednost u dinamičkoj procjeni volumnog statusa kod hemodinamski nestabilnog bolesnika.Continuous monitoring of cardiac output (CO) and maintenance of normovolaemia are the primary aims of haemodynamic (HD) optimization in every critical care patient. Previously, invasive monitoring and intermittent thermodilution with pulmonary artery catheterization were the main methods for determining CO. However, the methods more commonly used today are either minimally invasive or non-invasive. Minimally invasive methods of transpulmonary thermodilution (TD) in CO monitoring analyze the pulse pressure curve and are divided into older, calibrated and newer, non-calibrated systems. Dynamic parameters such as stroke volume variation (SVV) and pulse pressure variation (PPV) which can be continuously monitored, are far more precise in determining the optimal goal-directed volume therapy (GDVT) in comparison to the traditional static parameters such as CVP and PCWP. Modern non-invasive continuous methods, that are still not fully validated in clinical circumstances are: applanation tonometry, plethysmography, partial CO2 rebreathing technique, and pulse wave transit time measurements of CO. Thoracic electrical bioimpedance and bioreactance uses a weak alternating current, and through the phasic variations in the charge of the current during a systolic cycle, enables continuous analysis of the stroke volume (SV) curve. It is known that volume administration will not increase SV in roughly 50% of critically ill patients (fluid non-responders), therefore, prior to volume administration, through continuous SV/CO monitoring, it is important to assess whether a patient will have an adequate haemodynamic response to fluid administration (responders). There are some methods available for predicting the response to fluid administration, like measurement of variation in the diameter of the superior and inferior vena cava, the end-expiratory occlusion test, respiratory systolic variation test, SVV and PPV. The passive leg raising (PLR) test has the highest predictive score in dynamic assessment of the volume status in a haemodynamically unstable patient