Is There an Alternative to Intravenous or Neuroaxial Analgesia During Labor?

Izrazita bol koju žene proživljavaju tijekom poroda doživljava se kao nešto što svaka trudnica tijekom poroda mora iskusiti. No, moderna medicinska stajališta pokazuju da patofiziološke promjene u organizmu trudnice tijekom izrazito bolnih podražaja mogu biti štetne i za nju i za dijete. Intravenska primjena opioida i epiduralna analgezija danas su vjerojatno najčešće primjenjivane farmakološke metode analgezije tijekom poroda. Međutim, sve se više javlja interes za manje invazivnim metodama koje ne mogu uvijek značajno smanjiti bol, ali mogu smanjiti percepciju boli i time smanjiti potrebu za farmakološkim pripravcima ili invazivnim postupcima. U radu su opisane neke od mogućih alternativa klasičnoj analgeziji za porod.Severe pain during childbirth was considered something that every pregnant woman must experience. Nevertheless, from the point of view of modern medicine, it has been found that pathophysiological changes in pregnant body during painful contractions can be harmful to both the woman and the baby. Nowadays, intravenous administration of opioids and epidural analgesia are probably the most popular pharmacological methods for pain relief during childbirth. However, more and more parturient women are interested in less invasive methods that can not always significantly reduce the pain, but can reduce the perception of pain and thus reduce the need for the use of pharmacological preparations or invasive procedures. This article describes some of the possible alternatives to classical analgesia during labor

Obostrani pneumotoraks kao komplikacija perkutane traheotomije: prikaz slučaja

Percutaneous dilatational tracheostomy is a common surgical procedure that is becoming the method of choice in critically ill patients whenever prolonged airway secure and/ or ventilation support is needed. Although adverse events are relatively uncommon, serious life threatening complications can arise from this bedside procedure. We report a case of a 70-year-old female who developed extensive subcutaneous emphysema and bilateral pneumothorax immediately after a percutaneous dilatational tracheostomy procedure. Different mechanisms, such as damage to posterior or anterior tracheal wall, false passage or paratracheal placement or dislocation of the cannula are considered to be responsible for the development of pneumothorax and subcutaneous emphysema. Although bronchoscopic control after the tracheostomy procedure did not reveal any tracheal injury, we believe that subcutaneous emphysema and bilateral pneumothorax are most likely caused by procedure induced injuries of the trachea in addition to the applied high airway pressure induced by excessive or inappropriate ventilation. In our case report, we would like to emphasize that continuous bronchoscopic guidance during percutaneous tracheostomy is invaluable in decreasing the incidence of its overall complications, especially during enhancing the team experience.Perkutana dilatacijska traheotomija je učestali kirurški zahvat koji postaje metodom osiguravanja dišnoga puta u kritičnih bolesnika i bolesnika na dugotrajnoj mehaničkoj ventilaciji. Iako su popratni učinci relativno rijetki, metoda je vezana uz mogućnost nastanka za život opasnih komplikacija. Prikazujemo slučaj 70-godišnje žene kod koje je došlo do razvoja opsežnog potkožnog emfizema i obostranog pneumotoraksa neposredno nakon izvođenja perkutane traheotomije. Različiti mehanizmi kao što su oštećenje stražnjeg ili prednjeg zida dušnika, lažni prolaz ili paratrahealno postavljanje ili dislokacija kanile mogu se smatrati odgovornim za nastanak pneumotoraksa i potkožnog emfizema. U našem prikazu slučaja, iako nakon perkutane traheotomije bronhoskopskim pregledom nije nađeno oštećenje dušnika, smatramo da je uzrok nastanka potkožnoga emfizema i obostranog pneumotoraksa najvjerojatnije procedurom nastala ozljeda dušnika i primjena visokog tlaka u dišnim putovima izazvanog prejakom ili neodgovarajućom ventilacijom. Ovim prikazom slučaja željeli bismo naglasiti važnost bronhoskopske vizualizacije tijekom izvođenja perkutane traheotomije u prevenciji nastanka mogućih komplikacija, osobito u razdoblju usvajanja ove kliničke vještine

IS THERE ALTERNATIVE TO PARENTERAL OR NEURAXIAL ANALGESIA FOR LABOR AND DELIVERY?

Porođajnu bol većina žena opisuje kao najjaču bol koju su doživjele u životu. Porođajnu bol najčešće se ublažava neuroaksijalnom analgezijom ili parenteralnim analgeticima, ali kako te metode kao posljedicu mogu imati i značajne nuspojave, kako u majke tako i u djeteta, sve više raste zanimanje za druge farmakološke i nefarmakološke metode analgezije. Rjeđe korištene metode kao što je inhalacija dušičnog oksidula s kisikom ili primjena pudendalnog bloka također su učinkovite i korisne, osobito u trudnica koje imaju kontraindikaciju ili odbijaju neuroaksijalnu analgeziju. Rastući interes za što prirodnijim porođajem rezultirao je istraživanjem i uvođenjem niza nefarmakoloških metoda porođajne analgezije poput akupunkture ili akupresure, hipnoze, transkutane elektrostimulacije, porođaja u vodi ili na lopti, audioterapije i drugih. Nefarmakološkim metodama analgezije u pravilu se ne postiže potpuno uklanjanje boli, već modulacija bolnog doživljaja posredovana različitom psihološkom, mehaničkom ili električnom stimulacijom. Nefarmakološke metode kao i neke rjeđe korištene farmakološke metode smanjivanja boli pokazale su različit stupanj učinkovitosti te ovisno o tome trebaju imati svoje mjesto u liječenju boli pri porođaju.Women describe labor pain as the most severe pain they have experienced in their lives. Labor pain is usually treated with neuraxial analgesia or parenteral drugs. However, since these methods may have severe side effects on both the mother and the child, there is a growing interest in treating the pain with other pharmacological and nonpharmacological analgesic methods. Less frequently used methods such as inhalation of nitrous oxide with oxygen or pudendal nerve blockade are also effective and useful, especially in pregnant women who have a contraindication or refuse neuraxial analgesia. The growing interest in more natural labor has resulted in researching and introducing a range of nonpharmacological methods of labor analgesia such as acupuncture or acupressure, hypnosis, transcutaneous electrostimulation, water or ball delivery, audiotherapy, and others. Nonpharmacological analgesic methods do not achieve complete elimination of pain; instead, pain is alleviated using different psychological and mechanical stimuli. Nonpharmacological and less frequently used pharmacological methods of pain relief have shown different levels of effectiveness and, depending on this, they should have their place in the treatment of labor pain

AIRWAY MANAGEMENT IN A PATIENT WITH ACUTE BILATERAL VOCAL CORD PARALYSIS

Obostrana paraliza glasnica je rijetko, akutno životno ugrožavajuće stanje koje, ako se odmah ne pristupi zbrinjavanju dišnog puta, može završiti letalno. Najčešće nastaje nakon kirurških zahvata na glavi i vratu, nakon endotrahealne intubacije, u sklopu neuroloških sindroma ili stanja te kod malignih promjena na glasnicama. Klinička slika se najčešće postupno razvija od promuklosti i stridora do akutne respiracijske insufi cijencije. U ovom članku dajemo prikaz bolesnice koja je dovezena kolima hitne pomoći bez svijesti, tahidispnoična, cijanotična, hipotenzivna, slabo palpabilnih arterijskih pulzacija. Učinjena je hitna fi beroptička inspekcija kojom se verifi ciraju paralizirane glasnice u medijalnom položaju. Zbog navedenog nalaza, učinjena je hitna konikotomija, a nakon stabilizacije kliničkog stanja, i trajno zbrinjavanje dišnog puta postavljanjem kirurške traheostome u operacijskoj dvorani. Odmah nakon uspostavljanja dišnog puta došlo je do oporavka stanja svijesti i respiracijske funkcije.Bilateral vocal cord paralysis is a rare, life-threatening clinical condition with possibly lethal outcome if airway is not treated immediately. The most common causes of bilateral vocal cord paralysis are previous head and neck surgeries, endotracheal intubation, neurological causes, and laryngeal carcinomas. Clinical presentation includes change of voice quality and hoarseness as the fi rst symptom, with slow progression into stridor and acute respiratory insuffi ciency. This case report describes an elderly female patient admitted to our emergency unit in unconscious, tachydyspneic, cyanotic, hypotensive condition, with weak arterial pulse. Physical examination included urgent fi beroptic examination, with vocal cord midline fi xation seen. According to this fi nding, urgent conicotomy was performed, and later, when the patient was stable, tracheotomy as permanent airway management was performed in the operating room. Soon upon the airway management, the patient regained consciousness and respiratory suffi ciency

Antibiotic-induced toxic epidermal necrolysis - a case report

Toxic epidermal necrolysis (TEN) is severe cutaneousToxic epidermal necrolysis (TEN) is severe cutaneous hypersensitivity reaction characterized by necrosis of the epidermis and detachment of the epidermis and dermis that usually occurs as an idiosyncratic reaction to certain drugs. We report the case of a patient admitted to our Intensive Care Unit after an above-the-knee amputation who developed toxic epidermal necrolysis, possibly resulting from antibiotics therapy. Therapy included a combination of intravenous immunoglobulin with gentle early debridement of necrotic skin areas followed by wound coverage with a synthetic cover (Aquacel Ag®). This case report suggests that intensive wound management together with intravenous immunoglobulin might be beneficial in the treatment of patients with TEN.</p

Cijeli raspon respiracijske potpore kod trudnice s teškim oblikom infekcije COVID-19

Acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) in pregnant women can progress to a critical condition. In this paper, we present a case of a woman in the 28th week of gestation hospitalized due to respiratory insufficiency caused by COVID-19 infection and consequent bilateral pneumonia with development of severe acute respiratory distress syndrome. Noninvasive ventilation through a face mask was started but due to progression of respiratory insufficiency with high FiO2 and positive end expiratory pressure (PEEP), we decided to intubate the patient, after which obstetricians agreed to complete pregnancy by cesarean section. The clinical course was complicated by desaturation and bradycardia with recurring asystole which recovered after the use of atropine. The patient was increasingly difficult to mechanically ventilate on the PSIMV modality (tidal volume [TV] <200 mL). She was switched to ASV modality (TV up to a maximum of 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), after which peripheral saturation recovered to 89%. Due to inadequate mechanical ventilation, the patient was transferred to Dr. Fran Mihaljević University Hospital for Infectious Diseases in order to perform extracorporeal membrane oxygenation (ECMO). Owing to all of the measures taken, recovery followed after 13 days on ECMO.Akutni respiracijski sindrom uzrokovan novim koronavirusom (SARS-CoV-2) u trudnica se može komplicirati do kritičnog stanja. U ovom radu prikazujemo slučaj trudnice u 28. tjednu trudnoće hospitaliziranu zbog respiracijske insuficijencije uzrokovane infekcijom COVID-19 te posljedičnom obostranom pneumonijom i razvojem teškog ARDS-a. Započeta je neinvazivna ventilacija preko maske za lice, no zbog progresije respiracijske insuficijencije uz visoki FiO2 i PEEP odlučeno je provesti endotrahealnu intubaciju, nakon čega ginekolozi donose odluku o dovršenju trudnoće carskim rezom. Klinički tijek se komplicira desaturacijom te bradikardijom uz opetovane asistolije koje se oporave nakon primjene atropina. Bolesnicu se sve teže mehanički ventilira na modalitetu PSIMV (TV <200). Stoga je prebačena na modalitet ASV (TV do maskimalno 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), nakon čega se periferna saturacija oporavi do 89%. Zbog neodgovorajuće mehaničke ventilacije bolesnica se premješta u Kliniku za infektivne bolesti “Dr. Fran Mihaljević” zbog indicirane izvantjelesne membranske oksigenacije (ECMO). Zahvaljujući poduzetim mjerama uslijedio je oporavak nakon 13 dana ECMO-a

Interkostalna hernacija pluća nakon tupe traume i odgođeni izvanpleuralni hematom

Blunt chest trauma is an important cause of morbidity and mortality in traumatized emergency patients. We report the case of a 74-year-old man who suffered a glenohumeral joint dislocation, trans trochanteric femur fracture, multiple rib fractures, diaphragmatic rupture with chest herniation of the spleen and stomach associated with herniation of the lung through an anterior chest wall defect after blunt trauma. Although immediate surgical repair was performed, he developed a delayed complication of multiple rib fracture in the form of large extrapleural hematoma that had to be surgically removed. Due to massive pulmonary contusion and prolonged pulmonary collapse, we used surfactant to facilitate alveolar opening after evacuation of the hematoma.Trauma prsnog koša uzrokovana udarcem tupim predmetom značajan je uzrok mortaliteta i morbiditeta bolesnika u hitnoj medicinskoj službi. Prikazujemo slučaj sedamdesetčetverogodišnjeg bolesnika koji je kao posljedicu udarca teškim predmetom doživio dislokaciju ramenog zgloba, transtrohanternu frakturu bedrene kosti, obostranu serijsku frakturu rebara, rupturu dijafragme s hernijacijom slezene i želuca u prsište uz pridruženu interkostalnu ventralnu hernijaciju pluća kroz ozlijeđeno prsište. Unatoč hitnom kirurškom zbrinjavanju, kao kasna posljedica serijskog prijeloma rebara razvio se veliki izvan pleuralni hematom koji je bilo potrebno kirurški evakuirati. Zbog velike kontuzije pluća i dugotrajnog kolapsa alveola, nakon odstranjena hematoma primijenili smo surfaktant kako bi potpomogli otvaranje i održavanje alveola otvorenima