Multimodalni pristup liječenju poslijeoperacijske mučnine i povraćanja (PONV)

The paper shows a new, multimodal approach to the prevention of postoperative nausea and vomiting (PONV), which are among the most common complications in surgically treated patients. The approach combines the following procedures: risk assessment of postoperative nausea and vomiting, minimization of adverse effects of anesthesia and surgery, prophylaxis using drugs with anti-emetic effect, and optimization of therapy in case the complication develops. Besides reducing the incidence rate of PONV, such approach also reduces both the number of PONV-related serious complications and treatment costs.Ovim radom prikazan je novi, multimodalni pristup prevenciji i liječenju postoperacijske mučnine i povraćanja (PONV, od engl. postoperative nausea and vomiting) jedne od najčešćih komplikacija koja se pojavljuje u operiranih bolesnika. Objedinjuje sljedeće postupke procjenu rizika za razvoj PONV-a, minimaliziranje nepovoljnih učinaka anestezije i operacijskog zahvata, preventivnu primjenu kombinacije lijekova sa antiemetskim učinkom kao i optimalizaciju terapije ako se komplikacija razvije. Ovom metodom, pored snižavanja učestalosti PONV- a, smanjujemo i broj ozbiljnih komplikacija ove pojave kao i troškove liječenja

Multimodalni pristup liječenju poslijeoperacijske mučnine i povraćanja (PONV)

The paper shows a new, multimodal approach to the prevention of postoperative nausea and vomiting (PONV), which are among the most common complications in surgically treated patients. The approach combines the following procedures: risk assessment of postoperative nausea and vomiting, minimization of adverse effects of anesthesia and surgery, prophylaxis using drugs with anti-emetic effect, and optimization of therapy in case the complication develops. Besides reducing the incidence rate of PONV, such approach also reduces both the number of PONV-related serious complications and treatment costs.Ovim radom prikazan je novi, multimodalni pristup prevenciji i liječenju postoperacijske mučnine i povraćanja (PONV, od engl. postoperative nausea and vomiting) jedne od najčešćih komplikacija koja se pojavljuje u operiranih bolesnika. Objedinjuje sljedeće postupke procjenu rizika za razvoj PONV-a, minimaliziranje nepovoljnih učinaka anestezije i operacijskog zahvata, preventivnu primjenu kombinacije lijekova sa antiemetskim učinkom kao i optimalizaciju terapije ako se komplikacija razvije. Ovom metodom, pored snižavanja učestalosti PONV- a, smanjujemo i broj ozbiljnih komplikacija ove pojave kao i troškove liječenja

Analgezija nakon operacija tumora dojke

The choice of appropriate premedication and anesthetic technique may contribute to better postoperative analgesia. Intensity, frequency of occurrence, quality and duration of pain differ regarding the type of surgery: extent, site and duration of surgical procedure. They also depend on the patient\u27s psychological profile, his perioperative psychological and physiological adaptation and the quality of postoperative procedures. Pain after mastectomy and evacuation of axillary lymph nodes is classified as moderate in nearly half of the patients, however, 10-30% of them may experience severe pain. In the management of postoperative pain, opioid and nonopiod analgesics are used. Poorly treated pain after surgery may be considered a significant factor for increased morbidity and mortality resulting in a protracted hospital stay and, subsequently, increased treatment costs. The intensity of chronic pain, that might occur in a form of phatnom pain in the chest, shoulder and upper arm region following breast surgery, greatly depends on good surgical technique, successful management of acute postoperative pain, and well-performed radiotherapy, chemotherapy and physical therapy. Prolonged pain with adverse effects on the respiratory, cardiocirculatory and neuroendocrine function, may lead to psychological disorders, i.e. depression, and produce long-term effects in the central and peripheral nervous system. Pain therapy should therefore be included in a so-called multimodal concept of postoperative rehabilitation.Anesteziolog izborom premedikacije i anesteziološke tehnike može pridonijeti boljoj poslijeoperacijskoj analgeziji. Intenzitet, učestalost, kvaliteta i trajanje boli razlikuju se s obzirom na vrstu kirurškog zahvata: opseg, mjesto i trajanje operacije. Ovise također i o psihološkom profilu bolesnika, perioperacijskoj psihološkoj i fiziološkoj pripremi bolesnika, te o kvaliteti poslijeoperacijskih postupaka. Bol nakon mastektomije i evakuacije pazušnih limfnih čvorova u otprilike polovine bolesnika po jačini se ubraja u umjerenu bol, međutim, 10–30% bolesnika je doživljava kao jaku bol. U liječenju poslijeoperacijske boli upotrebljavaju se opioidni i neopioidni analgetici. Loše liječena poslijeoperacijska bol može se smatrati znakovitim čimbenikom povećanog morbiditeta i mortaliteta, koji rezultira produženim boravkom u bolnici i posljedično povećanim troškovima liječenja. Intenzitet kronične boli, koja se može pojaviti i u obliku fantomske boli u području prsnog koša, ramena i nadlaktice nakon operacije dojke ovisi o dobroj operacijskoj tehnici, uspjehu liječenja akutne poslijeoperacijske boli, dobro provedenoj radioterapiji, kemoterapiji i fizikalnoj terapiji. Prolongirana bol ima štetne posljedice na respiratornu, kardiocirkulatornu i neuroendokrinu funkciju, može dovesti do psihičkih poremećaje u smislu depresije, te izazvati dugotrajne posljedice u središnjem i perifernom živčanom sustavu. Terapija boli mora biti ugrađena u tzv.multimodalni koncept poslijeoperacijske rehabilitacije

Procjena rizika i prevencija plućnih komplikacijau perioperacijskom periodu

The incidence rate of pulmonary complications in the immediate postoperative period of non-cardiac surgery equals the incidence rate of cardiovascular complications. Patients undergoing surgery in the upper abdomen or any major abdominal operation are at the greatest risk. Exacerbation of chronic lung disease, respiratory failure, development of atelectasis and pneumonia are the most common and the most significant pulmonary complications in the early postoperative period. Patient’s health status, preoperative preparation and the type of surgery are the factors playing the leading role in the incidence of these complications. Prolonged hospitalization, increased treatment costs and longer recovery are additional significant issues requiring the routine introduction of procedures to reduce the incidence rate of perioperative pulmonary complications.Učestalost plućnih komplikacija u neposrednom poslijeoperacijskom periodu nakon nekardijalnih operacija jednaka je pojavnosti komplikacija od strane kardiovaskularnog sustava. Najvećem riziku izloženi su bolesnici nakon kirurških zahvata u gornjem abdomenu ili drugih velikih operacija u trbušnoj šupljini. Egzarcerbacija kronične plućne bolesti, respiratorna insuficijencija, razvoj atelektaza i posljedičnih pneumonija najčešće su i najznačajnije plućne komplikacije u ranom postoperacijskom periodu. Zdravstveni status bolesnika, prijeoperacijska priprema te vrsta kirurškog postupka glavni su čimbenici pojavnosti ovih komplikacija. Prolongiranje bolničkog liječenja, povećanje troškova i dugotrajniji oporavak su dodatni značajni problemi koji nam nameću potrebu za rutinskim uvođenjem postupaka kojim ćemo smanjiti učestalost plućnih komplikacija u perioperacijskom periodu

Procjena rizika i prevencija plućnih komplikacijau perioperacijskom periodu

The incidence rate of pulmonary complications in the immediate postoperative period of non-cardiac surgery equals the incidence rate of cardiovascular complications. Patients undergoing surgery in the upper abdomen or any major abdominal operation are at the greatest risk. Exacerbation of chronic lung disease, respiratory failure, development of atelectasis and pneumonia are the most common and the most significant pulmonary complications in the early postoperative period. Patient’s health status, preoperative preparation and the type of surgery are the factors playing the leading role in the incidence of these complications. Prolonged hospitalization, increased treatment costs and longer recovery are additional significant issues requiring the routine introduction of procedures to reduce the incidence rate of perioperative pulmonary complications.Učestalost plućnih komplikacija u neposrednom poslijeoperacijskom periodu nakon nekardijalnih operacija jednaka je pojavnosti komplikacija od strane kardiovaskularnog sustava. Najvećem riziku izloženi su bolesnici nakon kirurških zahvata u gornjem abdomenu ili drugih velikih operacija u trbušnoj šupljini. Egzarcerbacija kronične plućne bolesti, respiratorna insuficijencija, razvoj atelektaza i posljedičnih pneumonija najčešće su i najznačajnije plućne komplikacije u ranom postoperacijskom periodu. Zdravstveni status bolesnika, prijeoperacijska priprema te vrsta kirurškog postupka glavni su čimbenici pojavnosti ovih komplikacija. Prolongiranje bolničkog liječenja, povećanje troškova i dugotrajniji oporavak su dodatni značajni problemi koji nam nameću potrebu za rutinskim uvođenjem postupaka kojim ćemo smanjiti učestalost plućnih komplikacija u perioperacijskom periodu

Regional anaesthesia in cancer surgery: an update

Anaesthetic techniques can influence the cellular immune system and affect long term outcome. Cancer surgery itself and general anaesthetics, especially opioids, suppress immunity and therefore promote metastases. Regional anaesthesia attenuates the immunosuppressive effect of surgery. Local anaesthetics, contrary to opioids, stimulate the activity of natural killer (NK) cells during the perioperative period. All techniques of regional anaesthesia are very useful and applicable in cancer surgery, either for the anaesthesia itself or for the treatment of postoperative pain. The relationship between regional anaesthesia and cancer recurrence is one of the most interesting topics in anaesthesia today, but we must wait the results of prospective trials before definitive conclusions

Predskazatelji intenziteta akutne poslijeoperacijske boli u bolesnica s karcinomom dojke

To date, modern medicine does not have reliable tools for objectifying and measuring pain. In order to avoid the development of chronic pain, we must effectively treat intraoperative and postoperative acute pain. In this prospective study, we wanted to estimate whether and to what extent algometer and PSQ (Pain Sensitivity Questionnaire) and CSQ (Coping Strategies Questionnaire) predict the intensity and strength of postoperative pain. Accordingly, we wanted to adjust the analgesia protocol. The study was conducted from February to April 2019, at the University Hospital for Tumors in Zagreb, and included 100 patients who were admitted to the hospital for breast cancer surgery. Preoperatively all patients completed PSQ and CSQ questionnaires and pain sensitivity was measured with the algometer. The same analgesic protocol was applied to all patients. The pain was measured postoperatively by NRS (numeric rating scale) 2, 6, 12, 18, 24, 48 and 72 hours after the operation. According to the obtained results, the patients were grouped into the group of slightly sensitive, medium sensitive, or very sensitive. Correlation between PSQ and NRS was statistically significant in the group of very sensitive patients. Research has shown that algometer can identify very sensitive patients and enables planning the analgesic protocol prior the operation. We can conclude that the analgesic protocol applied during the study was successful in preventing postoperative pain.Sve do sada moderna medicina nema pouzdane alate za objektiviziranje i mjerenje boli. Učinkovitim liječenjem boli intraoperativno i postoperativno spriječavamo pojavu kronične boli. U ovom istraživanju željeli smo utvrditi možemo li i u kojoj mjeri pomoću algometra te PSQ i CSQ upitnika procijeniti intenzitet i snagu postoperativne boli te prema tome prilagoditi protokol analgezije. Istraživanje smo provodili od veljače do travnja 2019, u Klinici za tumore u Zagrebu, a obuhvatilo je 100 bolesnica koje su primljene u bolnicu radi operacije raka dojke. Preoperativno su sve bolesnice ispunile PSQ i CSQ upitnike, a algometrom smo izmjerili bolnu osjetljivost. Kod svih bolesnica primjenili smo isti analgetski protokol. Postoperacijska bol mjerena je NRS ljestvicom 2, 6, 12, 18, 24, 48 i 72 sata nakon operacije. Prema vrijednostima dobivenim algometrom, bolesnice su podijeljene u tri skupine; malo osjetljive, srednje osjetljive i vrlo osjetljive na bol. Korelacija između PSQ upitnika i NRS-a je statistički značajna u skupini vrlo osjetljivih bolesnica. Istraživanje je pokazalo da algometar može identificirati vrlo osjetljive bolesnice te omogučiti preoperativno prilagođavanje analgetskog protokola

Thromboprophylaxis in pregnant patient-specific risks

Background: Pregnancy and the puerperium are well-established risk factors for venous thromboembolism. Prothrombotic changes start after conception and normal coagulation returns eight weeks after the labour. The risk of DVT is approximately twice as high after caesarean delivery than vaginal birth. Specific risks: Inherited or acquired thrombophilias increase thromboembolic risk and influence the approach to thromboprophylaxis. Additional factors that increase thrombotic risk include immobilisation, such as bed rest for pregnancy complications, surgery including caesarean section, ovarian hyperstimulation during gonadotropin use for in vitro fertilisation, trauma and malignancy. The preferred agents for thromboprophylaxis in pregnancy are heparin compounds; these agents do not cross the placenta and therefore appears safe for the fetus. Because of the theoretical risk of epidural spinal haemorrhage in women receiving heparin that undergo epidural or spinal anaesthesia many anaesthesiologist will not perform neuraxial regional anaesthesia in women who have recently received heparin. Anaesthesia guidelines advise waiting to insert the needle at least 10 to 12 hours after the last prophylactic dose of LMWH, and at least 24 hours after the last therapeutic dose. Conclusion: Despite the increased risk of thrombosis in pregnancy, anticoagulants are not routinely indicated, because the risks usually outweigh the benefits. The exception is women on life-long anticoagulation or women with history of thrombosis or thrombophylia.Heparin therapy must be interrupted temporarily during the immediate peripartum interval to minimise the risk of haemorrhage and to allow for the option of regional anaesthesia