Analiza promjena arterijskog tlaka kod ugradnje zglobnih endoproteza u spinalnoj i općoj anesteziji

The aim of this study was to analyze hemodynamic changes in hypertensive and normotensive patients undergoing total hip or knee replacement in spinal and general anesthesia. Eighty patients who underwent total hip or knee replacement surgery in the period between July 2010 and February 2011 at Sveti Duh University Hospital were retrospectively evaluated. Seventeen patients underwent the operation in general anesthesia and 63 patients in regional anesthesia. They were allocated into groups of normotensive (n=24) or hypertensive patients (n=56). The anthropologic and hematologic parameters of normotensive and hypertensive patients were compared, as well as their blood pressures immediately before and during the operation. Blood pressure immediately before anesthesia induction, the highest and the lowest intraoperative blood pressures were recorded. Blood pressure immediately before anesthesia induction was significantly higher in hypertensive patients who underwent the operation in regional anesthesia compared to normotensive patients (158.48 mm Hg vs. 144.71 mm Hg, P<0.01). The highest intraoperative systolic blood pressure was also significantly higher in hypertensive patients operated on in regional anesthesia compared to normotensive patients (161.20 mm Hg vs. 146.76 mm Hg, P<0.01). The difference between the highest and the lowest intraoperative systolic blood pressure was significantly greater in hypertensive patients undergoing the operation in regional anesthesia compared to normotensive patients (46.41 mm Hg vs. 35.88 mm Hg, P<0.05). The results presented in this paper indicate that the fluctuations of intraoperative blood pressure were greater and the highest intraoperative systolic blood pressure was higher in hypertensive compared to normotensive patients undergoing the operation in regional anesthesia. In our study, there were no significant differences in intraoperative blood pressure between hypertensive and normotensive patients who underwent the operation in general anesthesia.U ovom radu su analizirane hemodinamske promjene u hipertenzivnih i normotenzivnih bolesnika tijekom operacija ugradnje totalnih endoproteza kuka i koljena u općoj i regionalnoj anesteziji. Retrospektivno su analizirani podatci 80 bolesnika kojima je od srpnja 2010. do veljače 2011. u Kliničkoj bolnici Sveti Duh ugrađena totalna endoproteza kuka ili koljena. Sedamnaest bolesnika operirano je u općoj anesteziji, a 63 u regionalnoj. Njih 24 je svrstano u skupinu normotenzivnih, a 56 u skupinu hipertenzivnih bolesnika. Uspoređivani su njihovi antropološki i hematološki pokazatelji, kao i intraoperacijsko kretanje tlaka. Zabilježen je njihov arterijski tlak neposredno prije uvoda u anesteziju, te najviši i najniži tlak tijekom zahvata. Arterijski tlak neposredno prije uvoda u anesteziju bio je statistički značajno viši u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (158,48 mm Hg prema 144,71 mm Hg, P<0,01). Također najviši intraoperacijski sistolički tlak bio je statistički značajno viši u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (161,20 mm Hg prema 146,76 mm Hg, P<0,01). Razlika između najvišeg i najnižeg intraoperacijskog sistoličkog tlaka bila je statistički značajno viša u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (46,41 mm Hg prema 35,88 mm Hg, P<0,05). Rezultati izneseni u ovom radu govore u prilog tome da su kolebanja intraoperacijskog tlaka veća, te da je najviši intraoperacijski sistolički tlak viši u hipertenzivnih u odnosu na normotenzivne bolesnike operirane u regionalnoj anesteziji. Nisu pronađene statistički značajne razlike intraoperacijskog tlaka između hipertenzivnih i normotenzivnih bolesnika operiranih u općoj anesteziji

Analiza promjena arterijskog tlaka kod ugradnje zglobnih endoproteza u spinalnoj i općoj anesteziji

The aim of this study was to analyze hemodynamic changes in hypertensive and normotensive patients undergoing total hip or knee replacement in spinal and general anesthesia. Eighty patients who underwent total hip or knee replacement surgery in the period between July 2010 and February 2011 at Sveti Duh University Hospital were retrospectively evaluated. Seventeen patients underwent the operation in general anesthesia and 63 patients in regional anesthesia. They were allocated into groups of normotensive (n=24) or hypertensive patients (n=56). The anthropologic and hematologic parameters of normotensive and hypertensive patients were compared, as well as their blood pressures immediately before and during the operation. Blood pressure immediately before anesthesia induction, the highest and the lowest intraoperative blood pressures were recorded. Blood pressure immediately before anesthesia induction was significantly higher in hypertensive patients who underwent the operation in regional anesthesia compared to normotensive patients (158.48 mm Hg vs. 144.71 mm Hg, P<0.01). The highest intraoperative systolic blood pressure was also significantly higher in hypertensive patients operated on in regional anesthesia compared to normotensive patients (161.20 mm Hg vs. 146.76 mm Hg, P<0.01). The difference between the highest and the lowest intraoperative systolic blood pressure was significantly greater in hypertensive patients undergoing the operation in regional anesthesia compared to normotensive patients (46.41 mm Hg vs. 35.88 mm Hg, P<0.05). The results presented in this paper indicate that the fluctuations of intraoperative blood pressure were greater and the highest intraoperative systolic blood pressure was higher in hypertensive compared to normotensive patients undergoing the operation in regional anesthesia. In our study, there were no significant differences in intraoperative blood pressure between hypertensive and normotensive patients who underwent the operation in general anesthesia.U ovom radu su analizirane hemodinamske promjene u hipertenzivnih i normotenzivnih bolesnika tijekom operacija ugradnje totalnih endoproteza kuka i koljena u općoj i regionalnoj anesteziji. Retrospektivno su analizirani podatci 80 bolesnika kojima je od srpnja 2010. do veljače 2011. u Kliničkoj bolnici Sveti Duh ugrađena totalna endoproteza kuka ili koljena. Sedamnaest bolesnika operirano je u općoj anesteziji, a 63 u regionalnoj. Njih 24 je svrstano u skupinu normotenzivnih, a 56 u skupinu hipertenzivnih bolesnika. Uspoređivani su njihovi antropološki i hematološki pokazatelji, kao i intraoperacijsko kretanje tlaka. Zabilježen je njihov arterijski tlak neposredno prije uvoda u anesteziju, te najviši i najniži tlak tijekom zahvata. Arterijski tlak neposredno prije uvoda u anesteziju bio je statistički značajno viši u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (158,48 mm Hg prema 144,71 mm Hg, P<0,01). Također najviši intraoperacijski sistolički tlak bio je statistički značajno viši u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (161,20 mm Hg prema 146,76 mm Hg, P<0,01). Razlika između najvišeg i najnižeg intraoperacijskog sistoličkog tlaka bila je statistički značajno viša u hipertenzivnih bolesnika operiranih u regionalnoj anesteziji u odnosu na normotenzivne (46,41 mm Hg prema 35,88 mm Hg, P<0,05). Rezultati izneseni u ovom radu govore u prilog tome da su kolebanja intraoperacijskog tlaka veća, te da je najviši intraoperacijski sistolički tlak viši u hipertenzivnih u odnosu na normotenzivne bolesnike operirane u regionalnoj anesteziji. Nisu pronađene statistički značajne razlike intraoperacijskog tlaka između hipertenzivnih i normotenzivnih bolesnika operiranih u općoj anesteziji

SEVERE VANCOMYCIN-INDUCED THROMBOCYTOPENIA IN A 53-YEAR-OLD WOMAN

Vankomicin i drugi lijekovi mogu se previdjeti kao uzrok trombocitopenije kod kritičnih bolesnika kod kojih su sepsa, heparinom izazvana trombocitopenija i diseminirana intravaskularna koagulopatija češći uzroci. U radu je prikazan slučaj teške trombocitopenije kod 53-godišnje bolesnice podvrgnute hitnoj laparotomiji zbog difuznog peritonitisa koja se razvila 24 sata nakon uvođenja terapije vankomicinom. Broj trombocita prije terapije vankomicinom iznosio je 101 x 109/L, a nakon 2 doze broj je pao na 8 x 109/L bez kliničkih znakova krvarenja. Višestruke transfuzije trombocita podigle su broj trombocita najviše do 48 x 109/L. Vankomicin je isključen iz terapije kao mogući uzrok trombocitopenije, a uveden je ciprofl oksacin. U serumu bolesnice dokazana su IgG antitrombocitna antitijela i uveden je u terapiju metilprednizolon 40 mg/dan. Stanje bolesnice i broj trombocita postepeno su se popravljali te je preoperativna vrijednost trombocita postignuta 10 dana nakon ukidanja vankomicina. Nalaz antitrombocitnih antitijela ovisnih o vankomicinu potvrđuje dijagnozu vankomicinom izazvane trombocitopenije, ali je test dostupan samo u specijaliziranim laboratorijima.Vancomycin and other drugs are often overlooked as causes of thrombocytopenia in critically ill patients in whom sepsis, heparin-induced thrombocytopenia and disseminated intravascular coagulation are considered as more common causes. We report a case of profound vancomycin-induced thrombocytopenia developing within 24 hours of treatment initiation. A 53-year-old woman with no signifi cant comorbidities underwent laparoscopic surgery for a left-sided ovarian tumor. Two days later, she developed severe sepsis with symptoms and signs of acute abdomen. Emergency laparotomy revealed a lesion of the sigmoid colon and fi brinopurulent peritonitis. Empirical antibiotic therapy started intraoperatively included i.v. metronidazole and gentamicin. On postoperative day 2, it was changed to i.v. meropenem and vancomycin according to the results of microbiological analysis of intraoperatively obtained abdominal fl uid and blood cultures. On the day vancomycin was started, platelet count was 101 x 109/L, falling to 8 x 109/L after two doses of vancomycin, with no clinical signs of bleeding. Vancomycin was excluded from therapy as a potential cause of thrombocytopenia and ciprofl oxacin was introduced. Multiple platelet transfusions elevated the count to a peak of just 48 x 109/L. IgG antiplatelet antibodies were detected in the patient’s serum and methylprednisolone 40 mg i.v. was added to therapy. The patient’s condition improved and she was discharged from the Intensive Care Unit on postoperative day 9 with platelet count of 50 x 109/L. The count returned to the preoperative value 10 days after discontinuation of vancomycin. In conclusion, vancomycin can cause severe thrombocytopenia and should be discontinued from therapy after more common causes have been excluded. Vancomycin dependent antibodies can be detected in some specialized laboratories, but these tests are not widely available

HOW TO IMPROVE PERIOPERATIVE BLOOD MANAGEMENT IN PATIENTS UNDERGOING TOTAL HIP OR KNEE REPLACEMENT SURGERY?

Operacije ugradnje totalnih endoproteza (TEP) kuka i koljena praćene su znatnim gubitkom krvi, što često zahtijeva transfuziju homologne (od davaoca) ili autologne (vlastite) krvi. S obzirom na rizike od transfuzije homologne krvi, cijenu krvnih pripravaka i elektivnu vrstu zahvata, u novije se vrijeme ističe važnost alternativnih postupaka kako bi se smanjila upotreba homologne krvi. U istraživanju smo prospektivno dokumentirali perioperacijski gubitak krvi i potrošnju krvnih pripravaka kod 65 konsekutivnih bolesnika podvrgnutih primarnim operacijama ugradnje TEP-a kuka (n=30) i koljena (n=35) u našoj ustanovi bez primjene metoda davanja autologne krvi. Ukupni gubitak krvi kod TEP-a kuka (1329,7±364,8 ml) i koljena (1427,3±660,4 ml) bio je u skladu s podacima u literaturi i bez značajne razlike između dvije skupine bolesnika. Međutim postotak bolesnika koji su primili homolognu krv (63,3% kod TEP-a kuka i 82,6% kod TEP-a koljena) bio je znatno veći nego kod sličnih bolesnika u novijim studijama. U radu su navedeni najvažniji postupci za smanjenje transfuzije homologne krvi koji uključuju protokol za perioperacijsko vođenje bolesnika, definiranje vrijednosti hemoglobina kao transfusion triggera, korekciju preoperacijske anemije intravenskim preparatima željeza, upotrebu jedne ili više metoda davanja autologne krvi, primjenu antifibrinolitika (traneksamična kiselina) i/ili druge komplementarne postupke. Na osnovi podataka o efikasnosti pojedinih metoda smatramo da rutinska upotreba krvnih produkata kod operacija TEP-a kuka i koljena nije opravdana ni izvan specijalnih ustanova i klinika za ortopediju.Total hip and knee arthroplasty is associated with significant perioperative blood loss, necessitating often blood transfusions. Because of risks and cost of allogenic blood transfusion and elective types of surgery several alternative methods have been developed to reduce allogenic blood use. We prospectively audited 65 consecutive patients undergoing primary total hip (THR; n=30) or knee replacement (TKR; n=35) at our Department of Orthopaedic Surgery which did not use autologous blood collection methods. Total blood loss in THR (1329.7±364.8 ml) and TKR (1427.3±660.4 ml) was similar to previously reported and without significant difference between the groups. However, we reported high transfusion rates with 63.3% of THR and 82.6% of TKR patients receiving allogenic blood. Important steps to reduce allogenic blood use would include implementation of restrictive transfusion protocols with a defined hemoglobin value as a transfusion trigger, correction of preoperative anemia with i.v. iron ± erythropoietin, use of one or more modalities of autologous transfusion (postoperative autotransfusion, preoperative blood donation), pharmacological agents like tranexamic acid (anti-fibrinolytic) and other complementary procedures. There is sufficient evidence in literature about the cost-benefit of certain methods which makes routine use of allogenic blood in THR and TKR surgery unacceptable even at general orthopaedic surgery departments

EARLY CAROTID ENDARTERECTOMY IN SYMPTOMATIC PATIENTS – OUR EXPERIENCE

U ovoj je studiji analiziran učinak endarterektomije unutarnje karotidne arterije (ACI) u bolesnika unutar tri tjedna od razvoja neurološke simptomatologije s obzirom na učestalost i vrstu neželjenih događaja u poslijeoperacijskom tijeku. U studiju su uključeni bolesnici sa simptomatskom stenozom visokog stupnja ACI, koji su preboljeli ishemijski moždani udar (IMU) ili tranzitornu ishemijsku ataku (TIA). Kod svih je bolesnika učinjena uzdužna karotidna endarterektomija u općoj anesteziji s uporabom intraluminalnog shunt-a. Praćenje bolesnika se odnosi na razdoblje između siječnja 2008. i listopada 2012. godine kada je operirano ukupno 69 simptomatskih bolesnika s visokim stupnjem stenoze ACI (70-99 %). Kontrolni ultrazvuk karotidnih arterija (CD) rađen je sedmi poslijeoperacijski dan te nakon jednog, tri, šest i dvanaest mjeseci, a nakon toga jednom godišnje. Od ukupnog broja operiranih (n = 69), 27 (39 %) bolesnika bilo je sa svježe preboljelim IMU-om koji su operirani unutar tri tjedna od razvoja neurološke simptomatologije, a najranije četrnaest dana nakon razvoja inzulta i 42 (61 %) bolesnika sa simptomima TIA-e, a koji su operirani neposredno nakon završetka prijeoperacijske obrade. Od poslijeoperacijskih neželjenih događaja došlo je do razvoja IMU-a u 2 (2,63 %) bolesnika i 2 odgođene restenoze (2,63 %) endarterektomirane unutarnje karotidne arterije koje su zahtijevale endovaskularno liječenje. Zaključujemo da provođenje rane endarterektomije u klinički odabranih bolesnika s visokim stupnjem stenoze ACI, shodno našim rezultatima i rezultatima drugih studija, ne nosi veći rizik od kasne endarterektomije, a zasigurno snižava postotak recidiva IMU i TIA-a, koji su najčešći u ranom razdoblju razvoja neurološke simptomatologije.Carotid endarterectomy is the gold standard as a therapeutic regimen for patients with high grade symptomatic stenosis of the internal carotid artery (ACI). This study analyzed the effect of early carotid endarterectomy in patients undergoing an operative procedure 2-3 weeks after the development of ischemic neurologic symptoms, considering the frequency and type of complications in the postoperative period. Patients included in this study were those with significant symptomatic ACI stenosis (70%-99%), which caused ischemic stroke or transient ischemic attacks (TIA). Patients with ischemic stroke were operated within twenty days of the initial neurologic event, whilst in those with symptoms of TIA, surgery was performed immediately after diagnostic work-up. In all cases, carotid endarterectomy was performed under general anesthesia with the use of protective intraluminal shunt. In the vast majority of cases, tucking or Kunlin’s sutures of the distal intima were applied. All procedures were performed between January 2008 and October 2012, and the total number of patients was 69. All patients underwent the same follow up program. Follow up carotid ultrasound was performed routinely on postoperative day 7 and at 1, 3, 6 and 12 months. In this study, 27 (39%) patients suffered minor ipsilateral stroke and 42 (61%) patients had TIA symptoms with verified significant ACI stenosis. Postoperative complications were observed in four (5.26%) patients. Two (2.63%) patients developed ischemic stroke after the procedure and two (2.63%) patients developed ACI restenosis in the late postoperative period and were treated by endovascular stenting. In conclusion, we found that early carotid endarterectomy was of greater benefit than delayed endarterectomy, which is in keeping with the published studies. The leading observation was that in selected patients, early carotid end- arterectomy was not associated with a higher risk of postoperative complications in comparison with delayed endarterectomy and could be performed safely

Incidence and clinical significance of post-dural puncture headache in young orthopaedic patients and parturients

Background and Aims: Post-dural puncture headache (PDPH) is a complication of spinal anaesthesia, influenced mostly by patient’s age, spinal needle size and design and, possibly, female gender. The purpose of this prospective observational study was to compare the frequency and clinical significance of PDPH in two patient groups at high risk for the development of PDPH, namely young parturients and orthopaedic patients, using 26-G and 27-G Quincke needles. Patients and Methods: The study included 56 parturients undergoing Caesarean section and 59 orthopaedic patients undergoing arthroscopic knee surgery, who received standard spinal anaesthesia using 26-G or 27-G Quincke needles. All patients were less than 40 years of age. The patients were visited on postoperative days 1, 2, and 4 or contacted by telephone and evaluated for the presence, characteristics and severity of headache, backache and other possible complications. Only posture dependent headache was regarded as PDPH with severity graded as mild, moderate and severe. Patient satisfaction was assessed by theirwillingness to have spinal anaesthesia in the future. Results: Orthopaedic patients were predominantly male (81.4%) and significantly younger than parturients (27.8±5.5 vs. 33.7±4.7 years, P<0.0001). Both groups had similar use of 26-G and 27-G needles, one attempt success rate at dural puncture, and high quality of spinal block. The incidence of PDPH in parturients was 14.3% and in orthopaedic patients 13.6%, which was not significantly different. Also, the severity of PDPH was similar, with mild headache in four out of eight PDPH patients in each group. The rate was similar with 26-G and 27-G needles. No patient required an epidural blood patch. Both orthopaedic patients and parturients expressed high satisfaction rate with spinal anaesthesia (96.6% and 94.6%, respectively). Conclusion: The rate of PDPH was similar in young orthopaedic patients and parturients but higher than in the literature. Low rate of severe headache, no need for epidural blood patch, and high patient satisfaction with spinal anaesthesia, make 26-G and 27-G Quincke needles an acceptable technique where pencil point needles are not available

Causes of SICU readmission and mortality: analysis of a 6-month period

Our aim was to evaluate the causes, risk factors and mortality rates associated with unexpected readmission to surgical intensive care unit (ICU). We performed a retrospective analysis of all adult patients readmitted to a 10-bed Surgical Intensive Care Unit (SICU) between 1 October 2013 and 31 March 2014. The readmission cases were collected from the hospital electronic information system. Data collected included rates, risk factor, causes and mortality associated with unexpected readmission to surgical ICU. Among the 333 patients admitted to the SICU during a six month period, 22 (7%) were readmitted. The most common reasons for readmission in our SICU were respiratory complications (27%) and cardiovascular instability (13.6%). Factors associated with a higher risk of readmission are older age and chronic health conditions, such as arterial hypertension (54.5%) and diabetes (40.9%). The mortality rate of SICU readmission is 22.7%. Intensive care is a very important part of postoperative care for most patients who undergo major surgery. As found in our study ICU readmission has been associated with a greater risk of hospital mortality and it is therefore important to identify patients at the highest risk of readmission

The use of laryngeal mask after failed intubation in thyroid surgery

Prema suvremenim algoritmima za zbrinjavanje otežanoga dišnog puta laringalna maska predstavlja sredstvo izbora za održavanje dišnoga puta. Međutim, laringalna maska nije uobičajeno sredstvo za održavanje dišnoga puta u kirurgiji štitnjače. U ovom radu prikazujemo dva slučaja uspješne primjene klasične laringalne maske u kirurgiji štitnjače nakon nemogućnosti endotrahealne intubacije.According to modern algorithms for difficult airway management, laryngeal mask is the tool of choice for maintenance of airway. However, laryngeal mask is not usually a device for maintaining airway in thyroid surgery. We present two cases of successful application of the classic laryngeal mask in thyroid surgery after impossible endotracheal intubation

Low dose spinal morphine and intravenous diclofenac for postoperative analgesia after total hip and knee arthroplasty

Background and Aims: Intrathecal (IT) morphine added to a spinal anaesthesia provides effective postoperative analgesia after hip and knee arthroplasty reducing the need for systemic opioids. To reduce the risk of side effects like pruritus, nausea/vomiting, and a more serious effect of respiratory depression, low dose IT morphine (0,1–0,3 mg) has been used. The aim of this prospective, randomized, double-blind study was to assess the analgesic efficacy of 0,2 mg IT morphine combined with postoperative i.v. diclofenac in the first 24 hours after hip and knee arthroplasty, the primary outcome measure being the number of patients without any additional opioid request. Side effects and possible complications of therapy and patient satisfaction with pain management were also recorded. Patients and Methods: 40 patients were randomized to receive spinal anaesthesia with levobupivacaine and 0,2 mL normal saline (control group) or 0,2 mg IT morphine. All patients received diclofenac 75 mg i.v. one and 10 hours postoperatively. Pain was assessed by numeric rating scale at 3,6,12 and 24 hours postoperatively and morphine 2 mg i.v. was given for inadequate analgesia. The third dose of diclofenac could be given 10–12 hours after the second dose for a pain score 3–4. Results: IT morphine group had significantly lower postoperative pain scores at all measured time intervals and used significantly less i.v. morphine. 76,2% of patients in the IT morphine group did not require any additional i.v. morphine compared to 11,1% of the control group. This resulted in significantly higher patient satisfaction despite common occurence of mild pruritus. Postoperative nausea/vomiting were frequent in both groups with no cases of respiratory depression. Conclusions: Low dose IT morphine added to regular postoperative i.v. diclofenac provides excellent analgesia after hip and knee arthroplasty and allows for a protocol without additional systemic opioids

Kako poboljšati transfuzijsko liječenje bolesnika podvrgnutih ugradnji totalnih endoproteza kuka i koljena? [How to improve perioperative blood management in patients undergoing total hip or knee replacement surgery?]

Total hip and knee arthroplasty is associated with significant perioperative blood loss, necessitating often blood transfusions. Because of risks and cost of allogenic blood transfusion and elective types of surgery several alternative methods have been developed to reduce allogenic blood use. We prospectively audited 65 consecutive patients undergoing primary total hip (THR; n = 30) or knee replacement (TKR; n = 35) at our Department of Orthopaedic Surgery which did not use autologous blood collection methods. Total blood loss in THR (1329.7 +/- 364.8 ml) and TKR (1427.3 +/- 660.4 ml) was similar to previously reported and without significant difference between the groups. However, we reported high transfusion rates with 63.3% of THR and 82.6% of TKR patients receiving allogenic blood. Important steps to reduce allogenic blood use would include implementation of restrictive transfusion protocols with a defined hemoglobin value as a transfusion trigger, correction of preoperative anemia with i.v. iron +/- erythropoietin, use of one or more modalities of autologous transfusion (postoperative autotransfusion, preoperative blood donation), pharmacological agents like tranexamic acid (anti-fibrinolytic) and other complementary procedures. There is sufficient evidence in literature about the cost-benefit of certain methods which makes routine use of allogenic blood in THR and TKR surgery unacceptable even at general orthopaedic surgery departments