Life Threatening Complications after Unsuccessful Attempt of the Guidewire Dilating Forceps Tracheostomy in Multi-Trauma Patient with Cervical Spine Injury

Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance

Single or double-injection technique in axillary block: the success of motor and sensor blockade

Background and Purpose: Axillary brachial plexus block is the method of choice for surgical procedures of upper arm except shoulder region. Distribution of local anaesthetic toward neurovascular space may be a reason for failed block. We investigated the axillary block effectiveness by singeand double-injection technique. Materials and Methods: Ninety patients (21–81 old; ASA I-IV) scheduled for upper arm surgery were divided in three equal groups during prospective, double-blind study. Nerve position was located with neurostimulator (Stimuplex® HNS 11)(0.5 mA, 2Hz and 0.1 ms). In Group S (single-shot), mixture of 30 mL (15 mL 0.5% bupivacaine and 15 mL 2% lidocaine) was injected only above axillary artery (25 mL around median and 5 mL around musculocutaneus nerve). In Group U and R (double-shot), the same mixture of local anaesthetic was applied above (10 mL around median and 5 mL around musculocutaneus nerve) and below axillary artery (15 mL around radial or ulnar nerve). Motor and sensor block were determined (Bromage scale, Pinprick method). Statistic analysis was done (SSP11.0). Results and Conclusions: Effective block analgesia and anaesthesia was achieved in shorter time in Group R (18+/4 and 26+/–3 min)(Group U: 34+/–4 and 41+/–3 min, Group S: 35+/–4 and 45+/–2 min) (P=0.0000) (Table 2). Block effectiveness was significantly higher after radial nerve stimulation (92%)(Group U 88% and S 76%) (P=0.630). Faster motor block was achieved in Group R (18+/–4)(Group U 26+/–3 and S 35+/–4 min) (P=0.000). Double-shot technique with primar radial nerve stimulation, allows better motor and sensor axillary block in comparison with single-shot technique

THE PARADIGM OF A SECOND OPINION IN THE FIELD OF PAEDIATRIC MEDICINE

Možda će roditelji bolesnog djeteta prije započetog liječenja izraziti želju da drugi liječnik pregleda postavljenu dijagnozu i plan liječenja. Drugo mišljenje omogućava roditeljima da budu sigurniji u točnost postavljene dijagnoze, ali ono ujedno olakšava razmatranje i donošenje odluke o najboljoj opciji tretmana. Neki su liječnici “konzervativniji”, neki “agresivniji”. Kad se od roditelja očekuje da odluče o tretmanu svoga djeteta, kliničar treba razjasniti nesigurnosti i evenutalne dvojbe. Prije ili tijekom liječenja roditelje je potrebno ohrabriti i podržati njihovu želju za dobivanjem drugog mišljenja - bez obzira na liječnički stav o nužnosti takvog postupanja. Načini dobivanja drugog stručnog mišljenja su različiti. Djelokrug tog područja nije u potpunosti rasvijetljen. Također nije jasno jamči li taj postupak pouzdanost. Ipak, drugo mišljenje katkad može značiti razliku između života i smrti.Before starting treatment, the parents of a sick child may want another doctor to review the diagnosis and treatment plan. Getting a second opinion allows them not only to confirm the diagnosis, but also to gain a different perspective on the child’s treatment options. Some doctors are more conservative and others more aggressive. When parents are invited to make choices their clinicians need to explain about clinical uncertainty and how individual values and preferences may relate to treatment decisions for their child. The options should be communicated in a clear manner, differences in opinion should be acknowledged and the doctor\u27s own preference stated. Parents need to be encouraged and supported to make their decision—whether or not it reflects their doctor\u27s preference. There are a number of ways to find specialists to consult for a second opinion: The scope of this phenomenon is not well understood . Also it is not clear whether it is warranted or not. However sometimes second opinions can mean the difference between life and death

Single or double-injection technique in axillary block: the success of motor and sensor blockade

Background and Purpose: Axillary brachial plexus block is the method of choice for surgical procedures of upper arm except shoulder region. Distribution of local anaesthetic toward neurovascular space may be a reason for failed block. We investigated the axillary block effectiveness by singeand double-injection technique. Materials and Methods: Ninety patients (21–81 old; ASA I-IV) scheduled for upper arm surgery were divided in three equal groups during prospective, double-blind study. Nerve position was located with neurostimulator (Stimuplex® HNS 11)(0.5 mA, 2Hz and 0.1 ms). In Group S (single-shot), mixture of 30 mL (15 mL 0.5% bupivacaine and 15 mL 2% lidocaine) was injected only above axillary artery (25 mL around median and 5 mL around musculocutaneus nerve). In Group U and R (double-shot), the same mixture of local anaesthetic was applied above (10 mL around median and 5 mL around musculocutaneus nerve) and below axillary artery (15 mL around radial or ulnar nerve). Motor and sensor block were determined (Bromage scale, Pinprick method). Statistic analysis was done (SSP11.0). Results and Conclusions: Effective block analgesia and anaesthesia was achieved in shorter time in Group R (18+/4 and 26+/–3 min)(Group U: 34+/–4 and 41+/–3 min, Group S: 35+/–4 and 45+/–2 min) (P=0.0000) (Table 2). Block effectiveness was significantly higher after radial nerve stimulation (92%)(Group U 88% and S 76%) (P=0.630). Faster motor block was achieved in Group R (18+/–4)(Group U 26+/–3 and S 35+/–4 min) (P=0.000). Double-shot technique with primar radial nerve stimulation, allows better motor and sensor axillary block in comparison with single-shot technique

A 10-Year Experience in the Treatment of Intraabdominal Cerebrospinal Fluid Pseudocysts

The aim of this retrospective study was to assess a ten-year experience in the treatment of rare complications of ventriculoperitoneal shunting – intraabdominal cerebrospinal fluid pseudocysts. At this time there are no data about incidence, clinical course and treatment of these complications in Croatia. Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. Retrospective data were obtained from 5 children with abdominal CSF pseudocysts, treated between 1996 and 2007. The incidence of intraabdominal CSF pseudocysts in our study is 2.9%. All patients were girls ranged in age from 4 to 12 years old (mean 8.8 years). In most cases etiology of hydrocephalus was congenital, idiopathic. Abdominal pain and distension were the most frequent clinical finding (4/5). Although infection has been reported as responsible for pseudocyst formation, we did not found it in our series. Laparotomy with cyst wall excision and catheter replacement was performed in 2/5 cases, and only cyst fluid aspiration with catheter replacement in 3/5 cases. Recurrence of the abdominal cyst was observed in one girl who was in terminal stadium of anaplastic ependymoma. It is our opinion that only catheter replacement and cyst fluid evacuation, as one of the treatment modalities, may be successful, even in large CSF intraperitoneal pseudocysts

Life threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy in multi-trauma patient with cervical spine injury [Životno ugrožavajuće komplikacije nakon neuspjela pokušaja perkutane traheotomije kod politraumatizitanog bolesnika s ozljedom vratne kralježnice]

Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance

Životno ugrožavajuće komplikacije nakon neuspjela pokušaja perkutane traheotomije kod politraumatizitanog bolesnika s ozljedom vratne kralježnice

Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance.Perkutana traheotomija (PTC) je klinički široko prihvaćena metoda osiguravanja dišnog puta u jedinicama intenzivne skrbi. Pravilna selekcija bolesnika prema opće prihvaćenim indikacijama i anatomskim markacijama uz kontinuiranu vizualizaciju postupka bronhoskopom (ili ultrazvukom) osigurava sigurno izvo|enje svakog njegovog segmenta. Sveukupni porast tehničkoga iskustva u izvo|enju PCT neminovno doprinosi smanjenju nastanka mogućih neželjenih komplikacija. Bolesnici sa ozljedom vratne kralježnice, sa ili bez pridružene ozljede vratnoga dijela le|ne moždine čine visokorizičnu skupinu bolesnika sa pojavom produžene respiracijske insuficijencije i potrebom za mehaničkom ventilacijom kod kojih je traheotomija u većini slučajeva neizbježna. Ovim opisom kliničkog slučaja želimo prikazati nastale višestuke, po život opasne komplikacije nakon neuspješnoga pokušaja izvo|enja PCT kod politraumatiziranog bolesnika sa pridruženom povredom vratnog dijela kralježnice. Njime tako|er želimo istaći važnost kontinuirane vizualizacije cjelokupnog postupka izvo|enja PTC (bronhoskopom ili ultrazvukom) kao i poštivanja graduacije stjecanja tehničke i praktične vještine osobe kao i tima koje je izvodi

THE PARADIGM OF A SECOND OPINION IN THE FIELD OF PAEDIATRIC MEDICINE

Možda će roditelji bolesnog djeteta prije započetog liječenja izraziti želju da drugi liječnik pregleda postavljenu dijagnozu i plan liječenja. Drugo mišljenje omogućava roditeljima da budu sigurniji u točnost postavljene dijagnoze, ali ono ujedno olakšava razmatranje i donošenje odluke o najboljoj opciji tretmana. Neki su liječnici “konzervativniji”, neki “agresivniji”. Kad se od roditelja očekuje da odluče o tretmanu svoga djeteta, kliničar treba razjasniti nesigurnosti i evenutalne dvojbe. Prije ili tijekom liječenja roditelje je potrebno ohrabriti i podržati njihovu želju za dobivanjem drugog mišljenja - bez obzira na liječnički stav o nužnosti takvog postupanja. Načini dobivanja drugog stručnog mišljenja su različiti. Djelokrug tog područja nije u potpunosti rasvijetljen. Također nije jasno jamči li taj postupak pouzdanost. Ipak, drugo mišljenje katkad može značiti razliku između života i smrti.Before starting treatment, the parents of a sick child may want another doctor to review the diagnosis and treatment plan. Getting a second opinion allows them not only to confirm the diagnosis, but also to gain a different perspective on the child’s treatment options. Some doctors are more conservative and others more aggressive. When parents are invited to make choices their clinicians need to explain about clinical uncertainty and how individual values and preferences may relate to treatment decisions for their child. The options should be communicated in a clear manner, differences in opinion should be acknowledged and the doctor\u27s own preference stated. Parents need to be encouraged and supported to make their decision—whether or not it reflects their doctor\u27s preference. There are a number of ways to find specialists to consult for a second opinion: The scope of this phenomenon is not well understood . Also it is not clear whether it is warranted or not. However sometimes second opinions can mean the difference between life and death