Pain Relief as an Integral Part of the Palliative Care

BACKGROUND: Palliative therapy represents active care for patients whose illness has such nature that is not responding to the curative treatment.  The palliative care aims to provide comfort and prevention from the suffering of the patients at the end of their life. Treatment of the pain presents an important integral part of palliative care.AIM: This article aims to discuss and answer to some of the analgesic regimes and therapeutic dilemmas.RESULTS: Pain control, in addition to the other treatments such as alleviation of psychological, sociological and spiritual problems, has a priority. The proper pain management can achieve a better quality of life for the patients and their families.CONCLUSION: It can be concluded that because of the different origin of the pain, the use of analgesic therapy should be individualised and adapted to the real need of every person. Finally, only a good organisation and institutionalisation of the palliative care in one society could permit better prevention of suffering at the end of the life

Присуство на анти-ТФ4/хепарин антитела кај пациенти профилактички третирани со еноксапарин после ортопедски оперативен зафат

Heparin-induced thrombocytopenia (HIT) is a condition caused by antibodies against the platelet factor 4 (PF4)/heparin complex. This significantly increases the risk of bleeding and thrombosis in patients, which is essential in the postoperative period. In this study we examined the rate of seroconversion of anti-PF4/heparin antibodies in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) after total knee or hip arthroplasty. The aims of the study were to assess the risk of HIT by evaluation of induction of anti-PF4/heparin antibodies in patients with RA and OA after total knee or hip arthroplasty, treated prophylactically with enoxaparine. Material and methods: We followed 36 patients aged 18 to 80 years, after total knee or hip arthroplasty, treated prophylactically with enoxaparine. Patients were divided in two groups: patients with RA and patients with OA.  They were examined for occurrence of HIT. Blood was sampled twice, from a peripheral vein, for immunologic tests. The first time it was done before enoxaparine application and the second time postoperatively 10 days after surgery. We noted demographic data, anti-PF4/heparin antibodies, erythrocyte sedimentation rate (ESR), CRP, RF, antiCCP and anti-nuclear antibodies Hep2 (ANA). Results: There was no significant difference in the values of anti-PF4/heparin antibodies in patients with RA and OA preoperatively. The presence of anti-PF4/heparin antibodies was significantly lower in RA patients compared to OA (7.14% versus 27.27%, p=0.034). There was no significant association between levels of anti-PF4/heparin antibodies and ESR, CRP, RF, CCP, ANA. Conclusion: The results obtained showed a lower level of anti-PF4/heparin antibodies in patients with RA than in patients with OA. This shows that there may be a difference in the generation of this antibody in patients with RA compared to patients with OA, prophylactically treated with enoxaparine after total knee or hip arthroplasty.Хепарин-индуцираната тромбоцитопенија (ХИТ) е предизвикана од антитела кон тромбоцитниот фактор 4 (ТФ4)/хепарин комплексот. Таа значително го зголемува ризикот од крвавење и тромбоза кај пациентите, што е особено есенцијално во постоперативниот период. Во оваа студија ја проценуваме стапката на сероконверзија на анти-ТФ4/хепарин антителата кај пациенти со ревматоиден артритис и остеоартритис по имплантација на протеза на колк или колено лекувани профилактички со еноксапарин. Целта на истражувањето беш да се процени ризикот од хепарин-индуцирана тромбоцитопенија преку евалуација на индукцијата на анти-ТФ4/хепарин антителата кај пациенти со ревматоиден артритис и остеоартритис по имплантација на протеза на колена или колк, лекувани профилактички со еноксапарин. Материјал и методи: Беа испитани 36 пациенти, на возраст од 18 до 80 години, по имплантација на протеза на колк или колено, лекувани профилактички со еноксапарин. Пациентите беа поделени во две еднакви групи, односно пациенти со ревматоиден артритис (РА) и пациенти со остеоартритис (ОА). Пациентите беа следени за време на хоспитализацијата на Клиниката за ортопедски болести за појава на ХИТ. Во два наврата беше земена венска крв, од периферна вена, за имунолошки иследувања. Прв пат тоа беше направено пред почеток на лекување со еноксапарин, а втор пат постоперативно, 10 дена по оперативниот зафат. Беа нотирани демографски податоци, анти-ТФ4/хепарин антитела, седиментација на еритроцити (ESR), CRP, RF, CCP, ANA, појава на ХИТ. Резултати: Немаше сигнификантна разлика во вредностите на анти-ТФ4/хепарин кај пациентите со ОА и РА предоперативно. Стапката на анти-ТФ4/хепарин антитела кај пациентите со РА беше сигнификантно пониска од онаа кај пациентите со ОА (7,14% наспроти 27,27%, р=0,034). Немаше сигнификантна поврзаност на вредностите на анти-ТФ/4 антителото со вредностите на ESR, CRP, RF, CCP или ANA. Заклучок: Резултатите укажаа на намалена инциденција на анти-ТФ4/хепарин антитела кај пациентите со РА во споредба со оние со ОА. Ова укажува дека постои разлика во анти-ТФ4/хепарин имуниот одговор кај пациенти со РА наспроти оние со ОА, профилактички лекувани со еноксапарин, по ортопедски оперативен зафат за имплантација на протеза на колк или колено

Улогата на пробиотикот „Диастоп пробио” во превенција на колонизација и инфекција со Clostridium difficile кај хоспитализирани пациенти

Mechanisms for adaptation of microbes from the intestinal microbiome determine their quantitative and qualitative presence in the intestinal tract. One of the most important disturbing factors of the intestinal microbiome, which enable oportunistic bacteria of the gut to reveal their pathogenic properties and cause infections is the antibiotic treatment of infections with different locations. Clostridium difficile infection is a typical example of this kind. The aim of our study was to investigate the possibility of the probiotic Diastop probio in preventing colonization and infection of intestine with Clostridium difficile, in hospitalized patients. Material and methods: A total of 32 patients who were treated with any two of the following antibiotics: Ampicillin, Ceftriaxon, Clindamycin, Ciprofloxacin, Imipenem, Meropenem, Amikacin, were included in the study. Sixteen patients represented the respondent group that received the probiotic "Diastop probio" simultaneously with their antibiotic treatment and the other 16 patients represented the control group who were treated with antibiotics only. Two specimens from each patient were obtained for detection of C.difficile colonization or infection with classical microbiological methods. Qualitative presence of normal intestinal flora was simultaneously analyzed. Results: The percentage of toxigenic  C.difficile strains was three times higher in the respondent group of patients than in the control group of patients (p< 0.05). A significantly lower percentage of disbalance in the normal intestinal flora was registered in patients receiving probiotic simultaneously with their antibiotic treatment. In all patients who had not received probiotics, the normal intestinal flora was reduced or completely absent and in 43.57% of them other pathogenic microorganisms: P. aeruginosa, VRE, ESBL+ E. coli and Candida albicans were detected. Conclusions: The treatment of hospitalised patients with probiotic "Diastop probio" simultaneously with their antimicrobial treatment, contributes to: significant decrease of intestinal flora disturbance, as an important prerequisite for colonization of C. difficile, significant decrease of the frequency of C.difficile infection, which decreases the risk for development of life- threatening complications. Treatment of hospitalized patients with the examined probiotic simultaneously with their antimicrobial treatment should prevent gut colonization with microorganisms, known as causes of hospital infections.Механизмите за адаптација со кои располагаат микроорганизмите од цревниот микробиом го одредуваат нивното квалитативно и квантитативно присуство. Еден од најзначајните фактори кои значајно го нарушуваат цревниот микробиом, овозможувајќи им на условно патогените бактерии да предизвикаат инфекции, е употребата на антибиотиците во терапија на голем број инфекции. Токму таква е инфекцијата која ја предизвикува C. difficile. Целта на нашата студија беше да се испита дали пробиотикот „Диастоп пробио” може да ја превенира колонизацијата и инфекција со C. difficile кај хоспитализирани пациенти. Материјал и методи: Во студијата беа вклучени вкупно 32 пациенти, кои беа третирани истовремено со два од наведените антибиотици: Ceftriaxon, Clindamycin, Ciprofloxacin, Imipenem, Meropenem и Amikacin. Шеснаесет пациенти ја сочинуваа групата на испитаници, кои го примаа и пробиотикот „Диастоп пробио”, а другите 16 пациенти од контролната група не добиваа пробиотик. Од сите пациенти беа добивани по два примерока за детекција на колонизација или инфекција со C. difficile, со класични микробиолошки техники. Истовремено беше проценувана и квалитативната застапеност на нормалната цревна флора. Резултати: Кај пациентите од групата испитаници, процентот на детектираните токсични соеви на C. difficile беше 3 пати повисок во однос на пациентите од контролната група (p<0,05). Истовремено кај пациентите кои примаа пробиотик  беше забележан сигнификантно помал процент на дизбаланс во нормалната цревна флора (p<0,05). Кај сите пациенти кои не примаа пробиотик нормалната цревна флора беше редуцирана или потполно отсутна, а 43,75% од нив беа носители на патогени микроорганизми: P. aeruginosa, VRE, ESBL+ E. coli и Candida albicans. Заклучок: Третирањето на хоспитализираните пациенти со пробиотикот „Диастоп пробио”, како дополнување на нивната антибиотска терапија, придонесува за: значајно намалување на дизбалансот во цревната флора, кој е важен предуслов за колонизација со C. difficile, значајно намалување на фреквенцијата на инфекцијата со C. difficile, што резултира со намален ризик за развивање на некоја од можните живото загрозувачки компликации. Ординирањето на испитуваниот пробиотик истовремено со спроведување на антибиотската терапија кај хоспитализираните пациенти би го спречило населувањето на нивниот дигестивен тракт со значајни микроорганизми, за кои е познато дека предизвикуваат интрахоспитални инфекции

Survey of Current Difficult Airway Management Practice

BACKGROUND: Even for the most experienced anesthesiologists “can’t ventilate can’t intubate†scenario in difficult airway management is challenging, and although rare it is life-threatening. AIM: The aim of this survey was to analyse the current practice of difficult airway management at our University teaching hospital. MATERIAL AND METHODS: A ten-question-survey was conducted in the Tertiary University Teaching Hospital “Mother Theresaâ€, Clinic for Anesthesia, Reanimation and Intensive Care. The survey included demographic data, experience in training anaesthesia, practice in management of anticipated and non-anticipated difficult airway scenario, preferable equipment and knowledge of guidelines and protocols. Responses were noted, evaluated and analysed with the SPSS statistical program. RESULTS: The overall response rate was very good; 94.5% answered the survey. During the assessment of the level of comfort with diverse airway equipment, there was diversity of answers due the experience of anaesthesia training, although the most frequent technique among all responders for anticipated difficult intubation was video laryngoscopy (48%). As for non-anticipated difficult intubation when conventional techniques failed to secure the airway most of the responders answered that they used supra-gothic airway device – laryngeal mask (38%) as a rescue measure. CONCLUSION: Airway assessment, adequate training, experience, and availability of essential equipment are the pillars of successful airway management

Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration

AIM: The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration.MATERIAL AND METHODS: In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well.RESULTS: The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren’t any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention.CONCLUSIONS: Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common

Evaluation of Total Thyroidectomy for Treatment of Benign Diseases of Thyroid Gland

BACKGROUND: The controversy of using total thyroidectomy (TT) in treatment of benign thyroid diseases still remains controversial over the rates of complication, mostly recurrence nerve palsy and hypocalcemia, compared to non-total thyroidectomies. The latest reports in this field of research showed that that the number of complications of TT is decreasing as the skills of surgeons increase. AIM: In this study, we reviewed 209 cases of total thyroidectomies for benign thyroid diseases where such surgery was indicated. The results were evaluated whether they support the previous reports that TT is save method of treatment of diffuse multinodular goiters, Graves’ disease thyroid adenomas with diffuse goiters and thyroiditis. METHODS: Two hundred and nine patients, 36 males and 173 females, medium age 47 (17–77) operated with TT between 2016 and 2018 were included in the evaluation study. We evaluated the: Diagnosis, indications for operation, pre-operative medication administration, laryngeal recurrent nerve palsy, hypocalcemia, hypoparathyroidism, and patohistology findings. The follow-up for hypocalcemia and laryngeal nerve palsy was performed 1 year postoperatively. RESULTS: The age of the patients was between 17 and 77 years, medium-range 47 years old. Of 209 patients, 173 (83%) were female and 36 (17%) male with a gender ratio of 1:4.8 males to females. Diagnoses before surgery were established as follows: Multinodular euthyroid goiter (MNEG) n = 106 (48.80%), multinodular toxic goiter n = 12 (5.74%), Graves’s disease n = 6 (2.87%), adenoma with multinodular goiter n = 73 (34.92%), and n = 16 (7.65%) patients with thyroiditis. Recurrence laryngeal nerve palsy (RLNP) occurred in 6 patients (2.87%), temporary within 3 months after the operation in 4 patients (1.92%) and permanent palsy within 6 months and more after an operation in 2 patients (0.95%). Voice hoarseness immediately and within 1 month after the operation was registered in 32 patients (15.3%). RLNP and hoarseness were registered mostly in patients with pre-operative problems, mostly with extra big MNEG. One of the permanent injuries of RLN was bilateral and all others were one sided. All patients were operated with normal pre-operative vocal cord movement findings. Post-operative hypocalcemia was registered in 35 patients (16.74%). Temporary nonsignificant hypocalcemia in 10 (4.78%), temporary significant hypocalcemia in 17 (8.13%), temporary severe hypocalcemia in 6 patients (2.87%), and permanent hypocalcemia in 2 patients (0.95%). CONCLUSION: Many studies have shown that the rate of complications is almost even for TT and NTT done for benign and malignant diseases of thyroid gland. Our data have shown that the risk of post-operative complications with TT is proportional to the number of complicated pre-operative findings of benign thyroid glands

Arterial blood gas alterations in retroperitoneal and transperitoneal laparoscopy

Background: Due to its numerous benefits laparoscopic surgery become very popular among physicians, hospitals and patients nowadays. In the urologic pathology laparoscopy can be performed with retroperitoneal or transperitoneal approach. Insufflation of CO2 for achieving visibility in both of the approaches can be absorbed in the vessels and can lead to alterations in arterial blood gasses. Material and Method: Study population was elective urologic patients scheduled for laparoscopic surgery. Investigated arterial blood gas variables were determined in three time points: T0 before induction – basal, T1 after one hour of CO2 insufflation, and T2 at the end of the surgery. Results: Alterations in arterial blood gasses were seen in T1 and T2 for PaO2 in retroperitoneal vs transperitoneal group 173.3 ± 19 vs 196.6 ± 29 (p < 0.003) and 95.5 ± 5.4 vs 101.1 ± 8.2 (p < 0.001). The PaCO2 was also statistically significant in second observed time point T1 in retroperitoneal vs transperitoneal group 45.9 ± 4.1 vs 38.2 ± 0.3 (p < 0.002). Conclusion: The findings that we have presented can suggest that both approaches are safe although hypercarbia is observed in retroperitoneal group. Key Words: arterial blood gasses, retroperitoneal laparoscopy, transperitoneal laparoscopy, urologic laparoscopy. Corresponding author: Aleksandra Gavrilovska-Brzanov, University Clinic for Anesthesia, Reanimation and Intensive Care, Skopje, Republic of North Macedoni

Postoperative complications in patients undergoing thyroid surgery

Background and objectives: Postoperative complications from thyroid surgery are numerous and may be shown on different levels. Some of these complications may be detrimental for patients, so minimization of the risks should be always considered. We evaluated the postoperative complications in patients after surgery of the thyroid gland at the Clinic for Thoracic Surgery, Skopje. Material and method: In retrospective manner, all patients undergoing thyroid surgery during the one-year period (1. January- 31. December 2017) were evaluated. Patients were divided into two groups, whereas group ST included patients who underwent goiter removal and subtotal thyroidectomy while group TT included patients in who total thyroidectomy was done. In both groups we analyzed the demographic data and the occurrence of postoperative (in the first 48 hours) complications (stridor, hoarseness, hemorrhage, nerve dysfunction, tracheomalacia, hypocalcemia and the need for reintubation and tracheostomy). Results: Total data from 197 patients was evaluated. 120 patients had subtotal thyroidectomy while total thyroidectomy had 77 patients. Postoperative complications occurred in significantly larger number of patients in the TT group (64.9 vs. 40%). Hoarseness (8.4% vs. 18.5%), stridor (18.3% vs. 9.2%) tracheomalacia (5% vs. 1.2%) and hematoma (2.5% vs. 3.8%) occurred in respect to the groups. Hypocalcaemia occurred in significantly larger number of patients in TT group. Permanent nerve injury was found in one patient in the same group and tracheotomy was done only in one patient. Conclusion: Overall results from our study show that the complications after thyroid surgery occur in all patients who undergo thyroid surgery. However, more severe complications and outnumbered are complications in patients who undergo total thyroidectomy. Key words: complications, occurrence, thyroid surgery, total thyroidectomy

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake