Strateški pristup ekstubaciji nakon otežane intubacije

Airway management relates to the period of tracheal intubation, maintenance of endotracheal tube in situ, and finally extubation. Problems related to difficult extubation still pose significant challenge for both anesthesiologists and intensivists. This article reviews current approach to extubation strategy following difficult intubation. Guidelines and algorithm may be helpful in order to ensure safe management of the patient during this delicate period of airway management.Osiguravanje dišnog puta odnosi se na razdoblje intubacije, održavanje endotrahealnog tubusa in situ i konačno na razdoblje ekstubacije. Problemi u vezi s otežanom ekstubacijom još uvijek predstavljaju značajan izazov za anesteziologe i intenziviste. Ovaj članak prikazuje suvremeni strateški pristup ekstubaciji nakon otežane intubacije. Smjernice i algoritmi mogu biti korisni za održavanje sigurnosti bolesnika u tom osjetljivom razdoblju osiguravanja dišnog puta

Začetak transplantacije bubrega u jugoistočnoj Europi

Organ transplantation is one of the most important medical achievements of the 20th century. Kidney transplantation is the most efficient method of renal replacement therapy. The first successful kidney transplantation in human was performed in 1954 in Boston, USA. In former Yugoslavia, the first kidney transplantation was performed on April 16, 1970 in Ljubljana, Slovenia, and second one on January 30, 1971 in Rijeka, Croatia. In both cases, the mother donated kidney to the son. In the article, we describe the prerequisite conditions for this operation, the characteristics of first patients, and the impact of transplantation program on the development of the hospitals and medical schools.Transplantacija organa zasigurno predstavlja jedno od najvećih dostignuća 20. stoljeća. Transplantacija bubrega je najučinkovitija metoda od svih oblika nadomještanja bubrežne funkcije. Prva uspješna transplantacija bubrega u ljudi je učinjena u Bostonu, SAD, 1954. godine. U bivšoj Jugoslaviji prva transplantacija bubrega je učinjena 16. travnja 1970. u Ljubljani, Slovenija, a potom 30. siječnja 1971. u Rijeci, Hrvatska. Darivatelj je kod oba bolesnika bila majka, a primatelj sin. U članku ćemo prikazati što je prethodilo ovim operacijama, značajke prvih bolesnika te utjecaj transplantacijskog programa na razvoj matičnih bolnica i fakulteta

Karakteristike i obrada otpadne vode koksne industrije

Coke is a high-calorie carbon mass obtained by dry distillation of coal, and used in various processes, the most significant of which is production of iron and steel. Coke production is present worldwide, especially in recent years when due to economic growth the global demand for steel is growing, which consequently increases demand for coke. During coke production, enormous amounts of toxic wastewater of extremely complex composition are generated. Priority pollutants that coking wastewater contains are phenols, cyanides, and thiocyanates. For successful treatment of such wastewater and achieving safety discharge standards, the application of a single process is insufficient. Accordingly, a combination of different physicochemical and biological treatment procedures, of which biological treatment is the most important, should be applied. In this article, a literature review of coking wastewater characteristics and treatment technologies is presented. In addition, this review addresses the complexity and limitations associated with coking wastewater treatment, with special emphasis on biological treatment methods. The aim of this review was to summarise the current knowledge on coking wastewater treatment technologies, which could eventually help optimisation of existing solutions.Koks je visoko kalorično umjetno gorivo koje se upotrebljava u proizvodnji željeza i čelika, a dobiva se suhom destilacijom ugljena. Proizvodnja koksa zastupljena je širom svijeta, osobito posljednjih godina, kad zbog ekonomskog rasta raste i svjetska potražnja za čelikom, što kao posljedicu ima i povećanu potrebu za koksom. Tijekom proizvodnje koksa nastaju enormne količine toksične otpadne vode izrazito kompleksnog sastava, a prioritetne onečišćujuće tvari koje sadrži su fenoli, cijanidi i tiocijanati. Za uspješno pročišćavanje te vrste otpadne vode i postizanje izlaznih parametara primjena jednog procesa nije dovoljna. Shodno tome, primjenjuje se kombinacija različitih fizikalno-kemijskih i bioloških postupaka obrade, od kojih je biološka obrada najvažnija. U ovom radu dan je literaturni pregled karakteristika otpadne vode koksne industrije i načini njihova pročišćavanja. Osim toga, ovaj pregled osvrće se na složenost i ograničenja povezana s pročišćavanjem koksne otpadne vode, s posebnim naglaskom na metode biološke obrade. Cilj ovog rada je sažeti dosadašnja znanja o otpadnoj vodi koksne industrije, što bi u konačnici pomoglo u optimizaciji postojećih rješenja

Factors Influencing Interdisciplinary Research and Industry-Academia Collaborations at Six European Universities: A Qualitative Study

The introduction of interdisciplinarity and industry-academia collaborations (IAC) into higher education institutions (HEIs) and curricula as tools for promoting sustainable development has been debated both in academic and non-academic contexts. While overall rising trends in the acceptance of interdisciplinarity and IAC exist, research has stressed difficulty in implementation and practices. We conducted eight focus groups at six European Universities (members of the SEA-EU alliance) and analysed the transcripts using Braun and Clarke's reflexive thematic approach to qualitative analysis in order to develop themes on barriers and facilitators to both conducting interdisciplinarity and IAC, as well as the inclusion of university students in interdisciplinary research. We observed that the main barriers to IR and IAC and the inclusion of students in such activities include traditional HEI structures focused on single-discipline approaches, a lack of joint platforms for IR and IAC, and academic differences (publication outcome differences, academic background). Likewise, a lack of funding (especially for early career researchers), employability (for students willing to do a research career), and a lack of validation by HEIs for researchers conducting IR and IAC are major barriers. To IDR- and IAC-related activities, a top-down approach is needed to restructure HEIs and make them more accommodating to both students and staff willing to conduct IR and IAC activities, thus refocusing them towards sustainability

LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH VENTRICULOPERITONEAL SHUNT

Razvojem i usavršavanjem laparoskopske kirurgije i poznavanjem njezinih patofizioloških posljedica na organizam, proširile su se indikacije za laparoskopske kirurške zahvate te se danas laparoskopska tehnika rabi kao terapijska i dijagnostička metoda. Iako se službeno ne smatra kontraindikacijom, ugrađeni ventrikuloperitonealni kateter nosi povišen perioperacijski rizik od laparoskopskih kirurških zahvata zbog mogućnosti povišenja intrakranijalnog tlaka tijekom pneumoperitoneuma. Od 1992. godine kada je učinjena prva laparoskopska kolecistektomija u Hrvatskoj, u Klinici za kirurgiju KB »Sveti Duh« laparoskopskom tehnikom operirana su tri bolesnika s ugrađenim ventrikuloperitonealnim kateterom. U sva tri bolesnika operacija i poslijeoperacijski tijek protekli su bez komplikacija. U ovom članku dajemo prikaz spomenutih triju slučajeva i kraći pregled literatureBecause of development of laparoscopic surgery and by knowing of its pathophysiological effects on organism, indications for laparoscopic surgery have become more extensive, so this method is today used for therapeutic and diagnostic procedures. Although ventriculoperitoneal shunt is not normally considered a contraindication for laparoscopic surgery, pneumoperitoneum is described as a cause of raised intracranial pressure. Since 1992 when the first laparoscopic cholecystectomy was done at the University Department of Surgery of Sveti Duh Clinical Hospital in Zagreb, three patients with implanted ventriculoperitoneal shunt were managed successfully laparoscopically. In all three patients, there were no complications during and after the surgery. In this paper we present our experience of three cases and short review of the literature

Bilateral vs. unilateral spinal anesthesia for varicose vein surgery in hypertensive patients

Background and Purpose: Cardiovascular system may be affected by spinal anaesthesia due to unavoidable sympathetic blockade. One of the most common side effect is hypotension. Hypertensive patients are particularly prone to developing hypotension during spinal anesthesia. The use of unilateral spinal anesthesia may restrict sympathetic block and avoid the undesired cardiovascular effects. The aim of this prospective, randomized study was to compare unilateral with bilateral spinal anesthesia in hypertensive patients undergoing surgery for varicose veins according to hemodynamic change. Material and Methods: Forty ASA II hypertensive patients scheduled for surgical repair of varicose veins were randomly allocated into two groups to receive bilateral (n=20) and unilateral (n=20) spinal anesthesia. Group S patients received bilateral spinal anesthesia with 3 ml isobaric 0.5% levobupivacaine (15 mg) and group US patients received unilateral spinal anesthesia with hyperbaric spinal solution (0.5% levobupivacaine 5 mg plus fentanyl 50 μg and 1ml of 10% glucose).We measured noninvasive mean arterial blood pressure and heart rate before spinal blockade and then after 5, 15, 30, and 45minutes.We also recorded the onset of motor and sensory blockade and side-effects. Results: There were no significant differences between two groups with respect to age, gender, weight, height and duration of surgery. In group S, 15 minutes after the initiation of the spinal block a statistically significant drop in the systolic and diastolic blood pressure from the baseline value was observed (p<0.05). Comparing systolic and diastolic blood pressure among groups, a statistically significant difference was also found 15 minutes after spinal injections (p<0.05). There were no statistically significant differences in heart rate between groups. Conclusion: In hypertensive patients undergoing surgery for varicose veins, unilateral spinal anesthesia is associated with minimal hemodynamic changes.We conclude that unilateral spinal anesthesia is an attractive alternative to bilateral spinal anesthesia in this group of patients

Local anaesthetic toxicity

Local anaesthetic drugs arewidely used for the provision of regional anaesthesia and analgesia. When used properly, they are safe and effective and have only few side effects. However, in case of an accidental intravascular injection or an injection of excessive dose, they can be toxic and neurologic and cardiovascular symptoms may occur. Systemic toxicity, although a rare complication, can be life threatening and resistant to treatment. This review offers a brief overview of the current understanding of the circumstances that cause systemic and cardiovascular toxicity in the daily clinical practice and the management of clinical signs and symptoms

Torakalna epiduralna analgezija za radikalnu cistektomiju pospješuje funkciju crijeva i u tradicionalnoj perioperacijskoj skrbi

Radical cystectomy is associated with significant morbidity and mortality due to complex surgery and comorbidities associated with advanced age of patients. In contrast to the surgery, which is clearly the procedure of choice for patients with invasive bladder cancer, the optimal anesthesiologic method is still under debate. Therefore, we retrospectively analyzed 85 patients having undergone radical cystectomy at our institution, either under combined epidural-general anesthesia (CEG A) or opioid based general anesthesia (GA). The intraoperative blood loss was significantly lower in CEG A group (497.37±354.13) than in GA group (742.31±403.69; p=0.006), due to induced hypotension. Consequently, blood transfusion requirements were lower in CEG A group (107.20±263.92) than in GA group (388.18±321.32; p=0.001). The incidence of postoperative ileus was also lower in CEG A group (p=0.024). There was no difference in analgesic efficacy, but a trend towards lower incidence of venous thrombosis and infection was noticed. The results of our study suggest that epidural anesthesia might have specific advantages in patients undergoing radical cystectomy.Radikalna cistektomija je praćena značajnom smrtnošću i pobolom zbog složenog kirurškog zahvata i komorbiditeta povezanog sa starijom dobi bolesnika. Za razliku od kirurškog zahvata koji je bez dvojbe metoda izbora za invazivni karcinom mokraćnog mjehura, optimalna metoda anestezije još je predmet rasprave. Stoga smo retrospektivno analizirali 85 bolesnika koji su u našoj ustanovi podvrgnuti zahvatu radikalne cistektomije u kombiniranoj torakalnoj epiduralnoj i općoj anesteziji ili u općoj anesteziji baziranoj na opioidima. Intraoperacijski gubitak krvi bio je značajno niži u skupini na kombiniranoj torakalnoj epiduralnoj i općoj anesteziji (497,37±354,13) nego u skupini na općoj anesteziji baziranoj na opioidima (742,31±403,69, p=0,006). Posljedično, količina transfundirane krvi bila je značajno niža u skupini koja je imala torakalnu epiduralnu anesteziju (107,20±263,92) nego u skupini na općoj anesteziji (388,18±321,32, p=0,001). Incidencija poslijeoperacijskog ileusa također je bila niža u skupini na kombiniranoj anesteziji (p=0,024). Nije uočena razlika u analgetskoj učinkovitosti, ali je zabilježen trend prema nižoj incidenciji venske tromboze i poslijeoperacijskih infekcija u skupini na kombiniranoj anesteziji. Rezultati naše studije impliciraju da bi torakalna epiduralna analgezija mogla imati specifične prednosti kod bolesnika podvrgnutih zahvatu radikalne cistektomije

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Opportunities for development of nautical tourism in the Republic of Croatia

Ovim završnim radom analiziraju se mogućnosti razvoja nautičkog turizma u Republici Hrvatskoj. Uz teorijske analize razumijevanja nautičkog turizma, provedeno je i kvalitativno i kvantitativno istraživanje pomoću kojega se dobio uvid o konkretnom stanju nautičkog turizma u Republici Hrvatskoj. Rezultati istraživanja među menadžerima hrvatskih marina pokazali su kako nautički turizam ima potencijal da ostvari velik udio u razvoju turizma Republike Hrvatske te da je marketing značajan čimbenik daljnjeg razvoja nautičkog turizma u Republici Hrvatskoj. Nažalost, prema istraživanju, čak 90 % menadžera tvrdi kako se nautički turizam ne promovira dovoljno u inozemstvu i Hrvatskoj te je posebno naglašena uloga online promocije kao najznačajnijeg oblika promocije nautičkog turizma. Nakon analize mogućnosti razvoja nautičkog turizma u RH te istraživanja među menadžerima hrvatskih marina, autorica je iznijela svoj zaključak.The paper analyzes the possibilities of nautical tourism development in the Republic of Croatia, and in addition to theoretical analyzes of understanding scientific tourism, a qualitative and quantitative research has been proven to gain insight into the specific state of nautical tourism in the Republic of Croatia. The results of research among Croatian marina managers showed that science tourism has the potential to achieve a large share in the development of tourism in the Republic of Croatia, that it is a marketing-significant factor in the further development of nautical tourism in the Republic of Croatia. Unfortunately, according to the research, as many as 90% of managers claim that nautical tourism is not promoted enough abroad and in Croatia, which is especially emphasized the role of online promotion as the most important form of promotion of nautical tourism. At the end of the paper, a comprehensive conclusion is drawn