Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi

Anesthesia and analgesia for FAUCS technique of cesarean section – case report

Carski rez povezan je s povećanim brojem komplikacija i velikom postoperativnom boli koja uzrokuje produljenje oporavka za tri do pet dana u odnosu prema vaginalnom porođaju. Novijom kirurškom metodom FAUCS (engl. French Ambulatory Cesarean Section) smanjuju se poslijeoperacijske komplikacije i bolnost. U Klinici za ženske bolesti i porodništvo Kliničkoga bolničkog centra Sestre milosrdnice u Zagrebu započelo se primjenjivati ovu operacijsku metodu u ožujku 2019. godine, prvi put u Hrvatskoj. Spinalna (subarahnoidalna) anestezija jest anestezija izbora za ovakav zahvat zbog potrebe sudjelovanja rodilje pri ekstrakciji novorođenčeta. Bolnost je zahvata manja, stoga spinalna anestezija iziskuje nižu dozu lokalnog anestetika u odnosu prema uobičajenoj standardnoj dozi za carski rez. Sniženje doze lokalnog anestetika omogućuje brži oporavak motoričke funkcije, a samim time i bržu mobilizaciju rodilje. Uz spinalnu anesteziju kombinira se analgezija blokom ravnine transversusa abdominis (engl. Transversus abdominis plane – TAP block) na kraju zahvata. Blok TAP-a doveo je do potpunog uklanjanja boli tijekom prva 24 poslijeoperacijska sata. Potreba za medikamentnom terapijom boli smanjena je na najmanju moguću, a opioidni analgetici nisu bili potrebni. Ovakva kombinacija poštednijega carskog reza i regionalne analgezije omogućila je brži oporavak rodilje, što je povezano s brojnim dobrobitima i za majku i za dijete. Donosimo prikaz jedne od prvih primjena metode FAUCS uz spinalnu anesteziju i blok TAP-a u Hrvatskoj.Cesarean section is correlated with a higher number of complications and higher postoperative pain which prolongs recovery in comparison with vaginal delivery for three to five days. With a relatively new and advanced surgical technique French Ambulatory Cesarean section (FAUCS) there are fewer postoperative complications and lower pain scores. In our Clinical Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, we started with this surgical technique at the beginning of 2019 for the first time in Croatia. The choice of anesthesia for this procedure is spinal anesthesia because the cooperation of the patient is essential for successful extraction of the neonate. As this procedure is less painful it is possible to reduce the dosage of spinal local anesthetic in comparison with the usual dose for classical cesarean section. Lower local anesthetic dose enables faster recovery of motor function, and allows faster mobilization of the parturients. We combined spinal anesthesia with Trans-Abdominal Plain (TAP) block at the end of the procedure. TAP block led to the complete elimination of postoperative pain during the first 24 postoperative hours. The necessity for pain medication therapy after day one was reduced to minimal doses, and opiate analgesics were not used. This combination of less painful cesarean section and regional anesthesia enabled faster patient recovery with many benefits for the woman and the newborn. In this case report we present one of our first cases

Kronična disekcija prsne aorte: liječenje ugradnjom endoluminalnog stenta

Chronic dissection of thoracic aorta is the subject of cardiac surgery and its treatment is burdened with high mortality and morbidity. The procedure of endoluminal stent graft placement in a 53-year-old male patient with an 8 cm wide false lumen is presented. Two stent grafts of 148 and 94 mm in length, both 44 mm in diameter, were applied. The surgical procedure lasted 6 hours. Thrombosis of the false lumen was registered perioperatively. The postoperative period proceeded without serious complications.Kronična disekcija prsne aorte predmetom je sretane kirurgije, a njezino liječenje opterećeno je visokom smrtnošću i pobolom. Prikazan je zahvat ugradnje endoluminalnog stenta u 53-godišnjeg bolesnika s 8 cm širokim lažnim lumenom. Primijenjena su dva stent usatka duljine 148 i 94 mm i promjera 44 mm oba. Kirurški zahvat trajao je 6 sati. Prijeoperacijski je zabilježena tromboza lažnog lumena. Poslijeoperacijski tijek protekao je bez ozbiljnijih komplikacija

Površinski prema kombiniranom (dubokom i površinskom) bloku vratnog pleksusa za karotidnu endarterektomiju: prospektivna studija u 324 bolesnika

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

NEW TECHNIQUES AND PROSPECTS IN INVASIVE TREATMENT IN VERTEBROLOGY

U članku su obrađene novosti i perspektive u invazivnom liječenju u vertebrologiji s naglaskom na interventne i poluinvazivne postupke te minimalno invazivnu kirurgiju u liječenju hernije intervertebralnog diska slabinske kralježnice. Osim toga opisane su novosti u neuroablativnim postupcima u liječenju križobolje, fiksaciji kralježnice i operativnom liječenju skolioza. Članak se osvrće i na metode koje se još ne primjenjuju kod nas, a koje dosta obećavaju kao što su rekonstrukcije nukleusa pulpozusa transplantacijom autolognih hondrocita, a prikazane su najnovije spoznaje u kirurgiji vratne kralježnice. Upozoreno je na uspješnost svake pojedine kirurške metode liječenja. Osim što je informativan, zajedno s odgovarajućim člankom o patofiziologiji spinalne boli, magnetskoj rezonanciji i konzervativnom liječenju ovaj tematski članak o najnovijim spoznajama u tom području može pomoći u pristupu bolesnicima.In this article authors outline new techniques and prospects in invasive treatment in vertebrology with emphasis on interventional and semi invasive procedures and minimally invasive surgery for lumbar disc herniation. They describe new approaches in neuroablative procedures for back pain treatment, in spinal fixation and in surgical treatment of scoliosis. Authors also report methods of great expectations which are not yet in use in our clinical practice but are promising like reconstruction of nucleus pulposus by autologous chondrocytes transplantation. New methods in cervical spine surgery are also discussed. The efficacy of each surgical method is pointed out. Apart from being informative, together with the corresponding article on patophysiology, magnetic resonance imaging and conservative treatment, these articles considering recent developments can be used as an aid in decision making when approaching these patients

GUIDELINES FOR INTERVENTIONAL AND INVASIVE TREATMENT IN PATIENTS WITH MECHANICAL BACK PAIN

Križobolja kao posljedica primarno mehaničkih poremećaja najčešći je tip križobolje, a obično se javlja u osoba mlađe i srednje životne dobi odnosno radno sposobne populacije. Zbog toga se smatra da je križobolja jedan od najvećih javnozdravstvenih pro¬blema. Liječenje bolnog sindroma kralješnice ovisi o brojnim čimbenicima, a općenito uključuje konzervativne i invazivne metode. Relativna indikacija za intervencijske i kirurške postupke je i dugotrajna križobolja, koja svojim simptomima, a ponajprije bolovi¬ma značajno onemogućava bolesnika u obavljanju aktivnosti svakodnevnoga života. Invazivno/kirurško liječenje primjenjuje se nakon najmanje 3 mjeseca konzervativnog liječenja, ako ono nije uspješno. Invazivni i kirurški postupci obuhvaćaju široki spektar intervencija od interventnih i poluinvazivnih postupaka, minimalno invazivnih operacija sve do opsežnih, invazivnih operacija koje uključuju instrumentaciju. Odabir intervencije temelji se na kliničkoj slici, trajanju i jačini bolova i drugih tegoba te na nalazima dijagnostičke obrade. Unatoč preporukama temeljenih na rezultatima kliničkih studija, individualizirani pristup svakom bolesniku i dalje ostaje glavni preduvjeti uspješnog liječenja.Back pain caused primarily by mechanical disorders is the most common type of back pain and it is usually found in young and middle-aged population, i.e. active population. This is why back pain is one of the most important public health problems. Tre¬atment of pain syndrome affecting spine depends on a variety of factors and generally includes conservative and invasive met-hods. Relative indication for interventional and surgical procedures is long lasting back pain, the symptoms of which, predomi¬nantly pain, cause significant problems for the patient on performing everyday activities. Invasive/surgical treatment is applied after minimally 3 months of unsuccessful conservative treatment. Invasive and surgical procedures comprise a wide spectrum of interventions, from interventional and semi-interventional procedures, minimally invasive procedures to extensive, invasive ope¬rations that include instrumentation. The choice of intervention is based on clinical findings, duration and severity of pain and other symptoms, as well as on diagnostic reports. Despite recommendations based on the results of clinical studies, individual approach to each patient is the main principle of successful treatment