Velika multinodularna struma s kompresijom traheje: indikacija za fiberoptičku intubaciju

Goiter or thyromegaly is one of the most common causes of mid tracheal obstruction (external compression or stenosis), which may be associated with difficult larynx visualization and/or difficult airway management, depending on the goiter size, type and ingrowth into the surrounding tissue. Iodine deficiency disorders are still one of the most common causes of goiter in the population of the African continent. These patients with goiter generally present for medical examination at an advanced stage of the disease. Mallampati test, thyromental distance and inter-incisor gap appear to provide the optimal combination for prediction of difficult visualization of the larynx. Video laryngoscopy examination of the subglottic region and inspection of tracheal deviation in the presence of tracheal compression without detected stenosis of the trachea is a standard and preferred technique in comparison with direct laryngoscopy. Intubation can be performed when vocal cords are visualized. The major difficulty on intubation is encountered in only 5.3% of patients with goiter. Large goiter need not always be associated with a higher incidence of difficult endotracheal intubation. Only two predicting factors for difficult airway assessment were identified in these patients: cancerous goiter (especially if compressive signs are present) and Cormack and Lehane grade III/ IV. The indication for fiberoptic intubation is tracheal compression or initial tracheal stenosis. Conventional tracheostomy has to be performed in goiter patients with identified tracheomalacia and/or high degree or tracheal stenosis.Multinodularna eutiroidna tiromegalija jedan je od najčešćih uzroka kompresije traheje i otežanoga pristupa dišnome putu. U 90% slučajeva etiološki je vezana uz nedostatan peroralni unos joda i/ili selena, a jednim dijelom i tireostatskim učinkom tvari poput tiocijanata. Tipične kliničke slike uznapredovale gušavosti susreću se i u endemskim područjima afričkog kontinenta (Zair, Južnoafrička Republika, Uganda, Sudan, Etiopija, Tanzanija, Nigerija). Većina ovih bolesnika dolazi s uznapredovalom bolešću kada je uslijed proširenosti strume već otežana vizualizacija larinksa i/ili teško dostupan dišni put. Pojedini bolesnici mogu izražavati simptome stenoze (kompresije) traheje uz disfagiju, promuklost i različit stupanj respiracijske insuficijencije, osobito uz medijastinalni prodor uvećane žlijezde. Specifičnost endotrahealne intubacije tada podliježe visokom proceduralnom pobolu i smrtnosti. Neovisno o veličini strume incidencija otežanog pristupa dišnome putu kod ovih bolesnika je 5,3%. Prediktorni testovi (Mallampati, Cormack-Lehane, tiromentalna udaljenost, pokretljivost vrata i sl.) uz prepoznavanje kliničkih simptoma doprinose optimalnom odabiru tehnike endotrahealne intubacije. Standardno pravilo uključuje video-laringoskopsku eksploraciju supra- i infraglotične regije te fiberoptičku endotrahealnu intubaciju otežanog dišnog puta

Velika multinodularna struma s kompresijom traheje: indikacija za fiberoptičku intubaciju

Goiter or thyromegaly is one of the most common causes of mid tracheal obstruction (external compression or stenosis), which may be associated with difficult larynx visualization and/or difficult airway management, depending on the goiter size, type and ingrowth into the surrounding tissue. Iodine deficiency disorders are still one of the most common causes of goiter in the population of the African continent. These patients with goiter generally present for medical examination at an advanced stage of the disease. Mallampati test, thyromental distance and inter-incisor gap appear to provide the optimal combination for prediction of difficult visualization of the larynx. Video laryngoscopy examination of the subglottic region and inspection of tracheal deviation in the presence of tracheal compression without detected stenosis of the trachea is a standard and preferred technique in comparison with direct laryngoscopy. Intubation can be performed when vocal cords are visualized. The major difficulty on intubation is encountered in only 5.3% of patients with goiter. Large goiter need not always be associated with a higher incidence of difficult endotracheal intubation. Only two predicting factors for difficult airway assessment were identified in these patients: cancerous goiter (especially if compressive signs are present) and Cormack and Lehane grade III/ IV. The indication for fiberoptic intubation is tracheal compression or initial tracheal stenosis. Conventional tracheostomy has to be performed in goiter patients with identified tracheomalacia and/or high degree or tracheal stenosis.Multinodularna eutiroidna tiromegalija jedan je od najčešćih uzroka kompresije traheje i otežanoga pristupa dišnome putu. U 90% slučajeva etiološki je vezana uz nedostatan peroralni unos joda i/ili selena, a jednim dijelom i tireostatskim učinkom tvari poput tiocijanata. Tipične kliničke slike uznapredovale gušavosti susreću se i u endemskim područjima afričkog kontinenta (Zair, Južnoafrička Republika, Uganda, Sudan, Etiopija, Tanzanija, Nigerija). Većina ovih bolesnika dolazi s uznapredovalom bolešću kada je uslijed proširenosti strume već otežana vizualizacija larinksa i/ili teško dostupan dišni put. Pojedini bolesnici mogu izražavati simptome stenoze (kompresije) traheje uz disfagiju, promuklost i različit stupanj respiracijske insuficijencije, osobito uz medijastinalni prodor uvećane žlijezde. Specifičnost endotrahealne intubacije tada podliježe visokom proceduralnom pobolu i smrtnosti. Neovisno o veličini strume incidencija otežanog pristupa dišnome putu kod ovih bolesnika je 5,3%. Prediktorni testovi (Mallampati, Cormack-Lehane, tiromentalna udaljenost, pokretljivost vrata i sl.) uz prepoznavanje kliničkih simptoma doprinose optimalnom odabiru tehnike endotrahealne intubacije. Standardno pravilo uključuje video-laringoskopsku eksploraciju supra- i infraglotične regije te fiberoptičku endotrahealnu intubaciju otežanog dišnog puta

Continuous wound infusion of levobupivacaine after total abdominal hysterectomy with bilateral salpingo-oophorectomy

Background and Purpose: Blockade of nociceptive afferents by the use of continuous wound infiltration with local anesthetics may be beneficial in a postoperative multimodal pain management after total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO). The role of continuous wound infusion of levobupivacaine for pain relief and postoperative recovery was evaluated. Materials and Methods: Fifty female patients (ASA I-III) scheduled for TAH and BSO were divided in two equal groups during prospective, double-blinded, placebo-controlled trial. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above the superficial abdominal fascia. Patients were randomly assigned to receive through the catheter 0.25% levobupivacaine (Group L) with 6ml bolus followed by an infusion of 7 ml/h during 48 h, or the same protocol with 0.9% NaCl (Group S). Simultaneously, patient-controlled analgesia provided intravenous morphine. All patients also received diclofenac 75 mg every 12 h for 48 h. Results and Conclusions: Median Visual Analogue Scale (VAS) was satisfactory. Compared with suprafascial saline, levobupivacaine infusion reduced morphine consumption during the first 48 h. The morphine consumption was significantly less (P<0.001) in Group L (6.91 +/– 3.17 mg) in comparison to Group S (50.61 +/– 14.02 mg). Nausea was less in Group L. Time to recover the bowel function was significantly reduced in Group L. No side effects were observed. Postoperative pain control with continuous wound infusion of 0.25% levobupivacaine after TAH with BSO provides effective analgesia, decreases opioid requirements and reduces time to recover the bowel function

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

Endokarditis nativne valvule uzrokovan meticilin-rezistentnim sojem bakterije Staphylococcus epidermidis u bolesnika s uznapredovalom cirozom jetre

We present a case of a 50-year-old man with advanced liver cirrhosis and native valve infective endocarditis caused by methicillin-resistant Staphylococcus epidermidis. Bacterial infections are one of the most common complications of liver cirrhosis, but reports of infective endocarditis in patients with liver cirrhosis are relatively rare. Because of vulnerability of patients with advanced cirrhosis for developing infections, it is necessary to pay attention to the pathogens that are sometimes considered contamination and actively seek for the seat of infection, even in less expected areas (e.g., native heart valves without a history of heart disease).Prikazujemo slučaj 50-godišnjeg muškarca s uznapredovalom cirozom jetre i endokarditisom nativne valvule uzrokovane meticilin rezistentnim sojem bakterije Staphylocoocus epidermidis. Bakterijske infekcije jedne su od najčešćih komplikacija ciroze jetre, ali su slučajevi infektivnog endokarditisa u bolesnika s cirozom jetre relativno rijetki. Zbog osjetljivosti bolesnika s uznapredovalom cirozom za razvoj infekcija potrebno je obratiti pozornost i na patogene koje ponekad smatramo kontaminacijom te aktivno tražiti mjesto infekcije, čak i u manje očekivanim područjima (kao što su nativne srčane valvule bez povijesti ranije srčane bolesti)

Femoral nerve block- or intravenous- guided patient control analgesiafor early physical rehabilitation after anterior cruciate ligament reconstruction in "fast-track" orthopedics: what is optimal?

Background and purpose: "Fast-track" orthopaedics characterizes early start of physical rehabilitation (PHR). Quality of mobilization depends on pain therapy success and preservation of motor function and muscle strength. Patient-control-analgesia (PCA), as an upgrade of continuous intravenous (IV) or regional analgesia (FB) makes the modern base in treatment of acute pain. The aim of the study was to determine more effective post-operative PCA-analgesia (IV-PCA vs. FB-PCA) for early PHR in "fast-track" orthopaedics. Materials and Methods: Prospective, observer-blinded study included 40 adults (bought gender, ASA I/II) scheduled for anterior cruciate ligament reconstruction (RACL). Spinal anaesthesia (12.5 mg, 0.5% levobupivacaine; G27-Pencil-Point) was performed in all patients. Patients were divided in two equal groups. In Group IV-PCA intravenous (fentanyl 0.5-1μg kg–1h–1), and in Group FB-PCA regional (femoral block: 0.125% levobupivacaine, 8 ml h–1) PCA-analgesia (Group IV-PCA: fentanil 10μg/8min/x6max; Group FB-PCA: 0.125% levobupivacaine, 8ml/30min/x3max) was established after surgery. Pain score (VAS) was assessed during 24-hours and accepted as satisfactory by 3. Diclofenac 75 i.v. was given in two doses, immediatelly and 12 hours after surgery. Paracetamol 1g was added intravenously if VAS was ³ 4. Start of early PHR was planned six hours after surgery. Result: FB- and IV-PCA provided equally effective analgesia during first 24-hours after RACL (VAS3). Early PHR was possible 6-hours after surgery in 85% of Group FB-PCA (Group IV-PCA=20%) (P=0,0001) due to significantly lower VAS 0,7+/–0,2 (Group IV-PCA=3,0+/–0,2)(P<0,0001). Residual motor block, presented in three patient (15%) with FB-PCA, disabled the onset of PHR.Additional analgesic dose wasmore need inGroup IV-PCA(40%) (Group FB-PCA=10%) (P<0,0001). Conclusion: FB-PCA allows more successful pain-free early PHR for orthopaedics "fast-track" ACL reconstruction compare to IV-PCA, excluding 15% of the FB-PCA patients in whom residual muscle weakness was present

MANAGEMENT OF ADULT SEPTIC PATIENT IN EMERGENCY UNIT

Pravodobna identifi kacija bolesnika sa sepsom je od krucijalnog značenja za ishod bolesnika. Od osobite je važnosti nadoknada tekućine. Stanje većine bolesnika zahtijeva agresivnu nadoknadu tekućine što je moguće ranije, odnosno tijekom prvih 24 sata liječenja počevši s brzim opterećenjem tekućinom zbog izražene teške hipovolemije. Otopine u dozi od >1000 mL kristaloida ili 300-500 mL koloida tijekom 30 minuta uz praćenje hemodinamskog stanja bolesnika i određivanje hitnog laboratorijskog panela (prije samog prijma) su prvi terapijski odabir. Prikazujemo slučaj starijeg bolesnika sa sepsom koji je imao akutno oštećenje bubrežne funkcije (AOBF) uzrokovano sepsom, povezano s produljenom hospitalizacijom i povećanim troškovima njege i liječenja no uz dobar klinički odgovor zbog pravodobnog terapijskog pristupa.Early identifi cation of sepsis is crucial to improve patient outcomes. Yet, sepsis can be diffi cult to differentiate in Emergency Unit. Sepsis treatment includes fl uid resuscitation as soon as possible, starting with >1000 mL of crystalloids or 500 mL of colloids for 30 min. Acute kidney injury is a serious complication of sepsis, associated with increased mortality, prolonged hospital stay and increased cost of care. In patients with sepsis, it would be useful to have some biomarkers of early organ damage, to improve the capacity for early recognition and diagnosis of acute kidney injury

MANAGEMENT OF ADULT SEPTIC PATIENT IN EMERGENCY UNIT

Pravodobna identifi kacija bolesnika sa sepsom je od krucijalnog značenja za ishod bolesnika. Od osobite je važnosti nadoknada tekućine. Stanje većine bolesnika zahtijeva agresivnu nadoknadu tekućine što je moguće ranije, odnosno tijekom prvih 24 sata liječenja počevši s brzim opterećenjem tekućinom zbog izražene teške hipovolemije. Otopine u dozi od >1000 mL kristaloida ili 300-500 mL koloida tijekom 30 minuta uz praćenje hemodinamskog stanja bolesnika i određivanje hitnog laboratorijskog panela (prije samog prijma) su prvi terapijski odabir. Prikazujemo slučaj starijeg bolesnika sa sepsom koji je imao akutno oštećenje bubrežne funkcije (AOBF) uzrokovano sepsom, povezano s produljenom hospitalizacijom i povećanim troškovima njege i liječenja no uz dobar klinički odgovor zbog pravodobnog terapijskog pristupa.Early identifi cation of sepsis is crucial to improve patient outcomes. Yet, sepsis can be diffi cult to differentiate in Emergency Unit. Sepsis treatment includes fl uid resuscitation as soon as possible, starting with >1000 mL of crystalloids or 500 mL of colloids for 30 min. Acute kidney injury is a serious complication of sepsis, associated with increased mortality, prolonged hospital stay and increased cost of care. In patients with sepsis, it would be useful to have some biomarkers of early organ damage, to improve the capacity for early recognition and diagnosis of acute kidney injury

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

Idiopathic hypoparathyreoidism, reversible cardiomyopathy and nephrogenic diabetes insipidus - case report

We are presenting a case of a 36-year-old patient with idiopathic hypoparathyroidism and reversible dilated cardiomyopathy as a result of hypocalcaemia. Twelve years later, the patient presented a picture of nephrogenic diabetes insipidus, which according to available literature has so far not yet been described