Ispiranje bronha surfaktantom kao metoda liječenja atelektaze u jedinici intenzivnog liječenja djece

The aim of this study was to assess the eff ect of fi beroptic aspiration and diluted surfactant administration on aff ected lungs in children with atelectasis. A convenience sample of 18 mechanically ventilated children were analyzed in this single center prospective study. The children had fi rst been treated unsuccessfully by respiratory physical therapy, after which they underwent fi beroptic aspiration. After aspiration, nine children were randomly selected to receive therapeutic lavage with diluted porcine surfactant; the remaining nine received the same quantity of saline solution. Several parameters of lung function, including positive end-expiratory pressure (PEEP) and oxygenation index (OI), as well as lung x-ray images were determined before aspiration and lavage, then at 6 and 12 h after lavage. In both groups, most of the measured parameters showed improvement from baseline at 6 h after treatment. Improvement was even more signifi cant 12 h after treatment. The surfactant group showed signifi cant improvement in comparison to the saline group. The impact of surfactant administration was most visible on the following parameters 12 h after treatment (p<0.001 in all cases): PEEP 5.22 (SD 0.44) in the saline group vs. 3.44 (SD 0.73) in the surfactant group; OI 3.84 (SD 1.13) vs. 2.1 (SD 0.38); and mean airway pressure (MAP) 8.56 (SD 0.88) vs. 6.33 (SD 0.5). In conclusion, fi beroptic aspiration is an effi cient treatment in pediatric intensive care patients. The observed benefi cial eff ects of therapeutic lavage with diluted surfactant should be confi rmed prospectively in a larger number of patients.Cilj je bio ispitati učinak bronhoskopske primjene razrjeđenog surfaktanta u liječenju atelektaze u djece. U ovu prospektivnu studiju je bilo uključeno 18 djece na mehaničkoj ventilaciji koja su neuspješno liječena fi zikalnom terapijom i bronhoskopskom aspiracijom. U devetoro bolesnika je nakon bronhoskopske aspiracije apliciran surfaktant u bronh zahvaćenog pluća, dok je u drugih devetoro aplicirana jednaka količina fi ziološke otopine. Mjereni su parametri plućne funkcije, PEEP, OI, a radiološka analiza rtg snimki provodila se prije aspiracije te 6 i 12 sati nakon ispiranja. U obje skupine većina mjerenih parametara pokazala je poboljšanje u odnosu na osnovne vrijednosti. Skupina kojoj je apliciran surfaktant pokazala je značajno poboljšanje u usporedbi s drugom skupinom. Najznačajniji učinak surfaktanta pokazao se na mjerenjima provedenim 12 sati nakon aplikacije (p<0,001 u obje skupine): PEEP 5.22 (SD 0,44) u skupini ispiranoj fi ziološkom otopinom prema 3.44 (SD 0,73) u skupini ispiranoj surfaktantom; OI 3,84 (SD 1,13) naspram 2,1 (SD 0,38); srednji talk u dišnom putu (MAP) 8,56 (SD 0,88) naspram 6,33 (SD 0,5). U zaključku, bronhoskopska aspiracija učinkovita je metoda u liječenju atelektaze u jedinici intenzivnog liječenja djece. Terapijski učinak ispiranja bronha razrjeđenim surfaktantom u takve djece mora se potvrditi u daljnjim istraživanjima na većem uzorku

Intraoperative volume restriction in esophageal cancer surgery: an exploratory randomized clinical trial

Aim To investigate whether the fluid volume administered during esophageal cancer surgery affects pulmonary gas exchange and tissue perfusion. Methods An exploratory single-center randomized clinical trial was performed. Patients with esophageal cancer who underwent Lewis-Tanner procedure between June 2011 and August 2012 at the Department of Thoracic surgery “Jordanovac”, Zagreb were analyzed. Patients were randomized (1:1) to receive a restrictive volume of intraoperative fluid (≤8 mL/kg/h) or a liberal volume (>8 mL/kg/h). Changes in oxygen partial pressure (Pao2), inspired oxygen fraction (FiO2), creatinine, and lactate were measured during and after surgery. Results Overall 16 patients were randomized and they all were analyzed (restrictive group n = 8, liberal group n = 8). The baseline value Pao2/FiO2 ratio (restrictive) was 345.01 ± 35.31 and the value six hours after extubation was 315.51 ± 32.91; the baseline Pao2/FiO2 ratio (liberal) was 330.11 ± 34.71 and the value six hours after extubation was 307.11 ± 30.31. The baseline creatinine value (restrictive) was 91.91 ± 12.67 and the value six hours after extubation was 100.88 ± 18.33; the baseline creatinine value (liberal) was 90.88 ± 14.99 and the value six hours after extubation was 93.51 ± 16.37. The baseline lactate value (restrictive) was 3.93 ± 1.33 and the value six hours after extubation was 2.69 ± 0.91. The baseline lactate value (liberal) was 3.26 ± 1.25 and the value six hours after extubation was 2.40 ± 1.08. The two groups showed no significant differences in Pao2/FiO2 ratio (P = 0.410), creatinine (P = 0.410), or lactate (P = 0.574). Conclusions Restriction of intraoperative applied volume does not significantly affect pulmonary exchange function or tissue perfusion in patients undergoing surgical treatment for esophageal cancer

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

DELIRIUM INCIDENCE IN PEDIATRIC INTENSIVE CARE UNIT

Delirij je ozbiljan neuropsihijatrijski poremećaj a delirij djece u jedinicama intenzivnog liječenja je kao klinički entitet neprepoznat. Rana dijagnoza delirija djece važna je zbog pravovremene terapije i raznih psihosocijalnih postupaka. Dijagnostika delirija u dječjoj populaciji je otežana jer postoji više ljestvica i testova ali niti jedan nije dovoljno specifičan i osjetljiv za procjenu mentalnog statusa djece u jedinicama intenzivnog liječenja. Algoritam za dijagnostiku i liječenje delirija djece u jedinicama intenzivnog liječenja ne postoji te je potrebno dodatnih kliničkih ispitivanja i radova radi poboljšanja dijagnostike i terapije tog ozbiljnog kliničkog entiteta.Delirium is a serious neuropsychiatric disorder and pediatric delirium (PD) is a similarly serious condition. PD is understudied and very often misdiagnosed, especially in pediatric intensive care units (PICU). It is important to early diagnose PD, so that early psychosocial interventions and therapy can be introduced. Valid diagnostic instruments are needed at PICU to assess PD. There are many scales and tests to diagnose delirium but none of them is specific enough to diagnose PD. Although PD is a serious complication at PICU, clinical guidelines for PD are still lacking, therefore additional investigations are needed to bring them out

Application of the procedural consolidation concept to surgical treatment of children with epidermolysis bullosa: a retrospective analysis

AIM: To assess the efficacy of the procedural consolidation concept (PCC) at reducing the number of sessions of general anesthesia necessary for treating children with epidermolysis bullosa (EB). ----- METHODS: We examined the records of children treated at Children's Hospital of Zagreb between April 1999 and December 2007. Children treated before the introduction of PCC in January 2005 (n=39) and after (n=48) were analyzed in order to determine the effect of PCC on the occurrence of complications, days of hospitalization, and number of hospitalizations. ----- RESULTS: During the study period, 53 patients underwent 220 sessions of general anesthesia for a total of 743 surgical interventions per session. Before the introduction of PCC (n=39 patients, 83 sessions), the median number of interventions per session was 2 (range 1-5), and after the introduction of PCC (n=48 patients, 137 sessions) it was 4 (range 3-7, P<0.001). After the introduction of PCC, the median number of complications per anesthesia session increased from 2 (range 0-10) to 3 (range 0-10) (P=0.027), but the median number of complications per surgical procedure decreased from 1 (range 0-10) to 0.6 (range 0-2.5) (P<0.001). PCC lengthened each anesthesia session from a median of 65 minutes (range 35-655) to 95 minutes (range 50-405), (P<0.001). Total length of hospitalization was similar before (median 1, range 1-4) and after (median 1, range 1-3) introduction of PCC (P=0.169). The number of hospitalization days per procedure was 3 times lower after the introduction of PCC (median 0.3, range 0.2-3) than before (median 1, range 0.75-1.7) (P<0.001). ----- CONCLUSION: PCC should be considered an option in the surgical treatment of children with EB

Anaesthetic Management in Patients With Bullous Epidermolysis

Bulozna epidermoliza (engl. bullous epidermolysis; lat. epidermolysis bullosa - EB) rijetka je, genetički i klinički heterogena skupina bolesti koju karakterizira pretjerana sklonost odvajanju slojeva kože i sluznica nakon mehaničke traume. Bolest značajno utječe na bolesnikovu kvalitetu života. Kirurško je liječenje simptomatsko iako se intenzivno radi na novim metodama staničnoga i molekularnoga liječenja. Cilj je ovoga preglednog članka ukazati na anesteziološke specifičnosti populacije bolesnika s buloznom epidermolizom, na anesteziološke tehnike u prijeoperacijskome zbrinjavanju i prevenciji nastanka komplikacija te na poslijeoperacijsko liječenje boli.Bullous epidermolysis is a rare, genetically and clinically diverse group of diseases, characterized by an excessive susceptibility of the skin and mucosa to a mechanical trauma resulting in their separation from underlying tissues. The disorder seriously affects the patient’s quality of life. Treatment is symptomatic, although new cellular and molecular therapies are currently under investigation. The aim of this review article is to point out the anaesthesiological specifics in the population of EB patients, anaesthesiologic techniques in preoperative care and prevention in of complications, as well as postoperative pain management

Comparison of Perioperative Adverse Effects of Bilateral and Unilateral Spinal Anaesthesia

Hemodinamske promjene tijekom spinalne anestezije izravno su povezane s veličinom simpatičke blokade. Unilateralnom spinalnom anestezijom, u odnosu na standardnu bilateralnu spinalnu anesteziju, postiže se manja blokada simpatikusa, a neželjeni se učinci mogu izbjeći. Svrha je ovoga istraživanja usporediti učestalost neželjenih učinaka kod unilateralne i standardne bilateralne spinalne anestezije. U istraživanje je bilo uključeno 52 bolesnika statusa ASA I i II predviđenih za elektivni kirurški zahvat spinalnom anestezijom na Klinici za anesteziologiju, reanimatologiju i intenzivno liječenje i Klinici za kirurgiju Kliničke bolnice „Sveti Duh” u Zagrebu. Bolesnici su slučajnim odabirom podijeljeni u dvije skupine. U skupini US (n = 26) bolesnici su podvrgnuti unilateralnoj spinalnoj anesteziji s hiperbaričnom anestetičkom otopinom (5 mg 0,5 %-tnoga levobupivakaina, 50 μg fentanila i 1 mL 10 %-tne glukoze). Skupina BS (n = 26) bolesnika podvrgnuta je bilateralnoj spinalnoj anesteziji s 3 mL izobaričnoga 0,5 %-tnog levobupivakaina (15 mg). Poslije operacije neželjeni učinci kao što su glavobolja, mučnina, povraćanje, problemi s mokrenjem te vrijeme prestanka motoričkoga bloka i vrijeme prvoga ustajanja praćeni su anketama. Praćeni su i podaci o pojavi hipotenzije i bradikardije tijekom anestezije. U usporedbi s bilateralnom spinalnom anestezijom vrijeme do povratka mišićne snage (2,9 ± 1,1 sat prema 4,2 ± 1,4 sata, p < 0,001) i vrijeme prvoga ustajanja (9,9 ± 7,2 sata prema 19,8 ± 6,9 sati, p < 0,001) kraće je u bolesnika koji su anestezirani unilateralnom spinalnom anestezijom. Učestalost problema s mokrenjem također je manja u toj skupini (2 prema 9, p = 0,017), a stupanj zadovoljstva anestezijom veći (20 prema 13, p = 0,044). Zaključuje se da unilateralna spinalna anestezija smanjuje učestalost problema s mokrenjem i da je povezana s bržim oporavkom i većim zadovoljstvom bolesnika nego standardna bilateralna spinalna anestezija.Hemodynamic changes during spinal anaesthesia are directly related to the size of sympathetic blockade. In contrast to standard bilateral spinal anaesthesia, unilateral spinal anaesthesia may restrict sympathetic block and avoid undesired effects. The purpose of this study was to compare the incidence of adverse effects between unilateral and bilateral spinal anaesthesia. The study included 52 patients with ASA status I and II scheduled for elective surgery under spinal anaesthesia at Department of Anaesthesiology, Resuscitation and Intensive Care, and Department of Surgery of University Hospital “Sveti Duh” in Zagreb, Croatia. The patients were randomly divided in two groups. Patients in the US group (n = 26) underwent unilateral spinal anaesthesia with hyperbaric anaesthetic solution (5 mg of 0.5% levobupivacaine, 50 μg fentanyl, and 1 mL of 10% glucose). Patients in the BS group (n = 26) received bilateral spinal anaesthesia with 3 mL isobaric 0.5% levobupivacaine (15 mg). Adverse effects such as headache, nausea, vomiting, urinary retention, regression of motor block, and first time of getting out of bed were surveyed postoperatively. During anaesthesia, adverse effects such as hypotension and bradycardia were also recorded. The time needed to return muscle strength (2.9 ± 1.1 h vs. 4.2 ± 1.4 h, p < 0.001) and time elapsed before getting out of bed for the first time (9.9 ± 7.2vs. 19.8 ± 6.9 h, p < 0.001) was shorter in the unilateral group of patients than in bilateral group of patients. The incidence of urinary retention was lower (2 vs. 9, p = 0.017) and level of satisfaction was higher (20 vs. 13, p = 0.044) in the US group of patients. In conclusion, unilateral spinal anaesthesia reduces the incidence of disturbances of micturition and is associated with faster recovery and greater patient satisfaction than the standard bilateral spinal anaesthesia

TAPENTADOL THERAPY IN CHRONIC PAIN MANAGEMENT: OUR EXPERIENCE

Tapentadol je novi lijek registriran u retard obliku za umjerenu i jaku kroničnu bol koji svojim spektrom djelovanja pokriva i nociceptivnu i neuropatsku komponentu boli. Analgetski se učinak postiže djelovanjem dvaju sinergističkih mehanizama: agonističkim učinkom na mi opioidne receptore (MOR-agonizam) i inhibicijom ponovnog preuzimanja noradrenalina (NRI). Cilj: Usporediti naša iskustva o učinkovitosti i podnošljivosti tapentadola s iskustvima drugih istraživača u svijetu. Metode: U istraživanje su uključena 92 bolesnika iz naše ambulante za bol, kojima je bilo indicirano propisati tapentadol-retard u dozi od dva puta 50 mg ili višoj. Pratili smo povoljni učinak na smanjenje bolova prema vizualno-analognoj ljestvici (VAS) te vrstu i učestalost neželjenih učinaka lijeka. Bilježene su i daljnje preporuke za prilagodbu doze odnosno prekid terapije. Rezultati: Pojava povoljnog djelovanja tapentadola na smanjenje kronične boli kod različitih bolnih sindroma pokazala se u 66 %, ispitanika. Postotak nuspojava, od blažih do težih, iskazalo je 43 % bolesnika. Pedeset i četiri % korisnika tapentadola odustalo je od terapije, 37 % zbog nuspojava, 15 % zbog nezadovoljstva kontrolom boli i 2 % zbog neodobravanja obiteljskog liječnika. Zaključak: Našim istraživanjem potvrđena je dobra učinkovitost tapentadola na smanjenje boli. Nuspojave se u ukupnom broju javljaju sličnom učestalošću kao u podatcima iz literature, i to rjeđe nego kod terapije klasičnim opioidima. Uočena je visoka stopa prekida terapije što je u prvom redu pripisano pojavi neželjenih učinaka.Tapentadol is a novel analgesic registered in slow-release form for medium-intensity and intense chronic pain, which targets both the nociceptive and neuropathic component of the pain signal. It utilizes two synergistic mechanisms: MOR – mu opioid receptor agonism and NRI – norepinephrine reuptake inhibition. The goal of this study was to compare the effectiveness of pain management and tolerability of tapentadol in our clinical experience with existing reports from abroad. The study included 92 patients from our pain management clinic who were prescribed slow-release tapentadol in doses of at least 50 mg twice daily. We tracked the effectiveness of pain management recorded using the visual analog scale, as well as the appearance and type of adverse effects. Further directions for dose adjustment or discontinuation of therapy were also recorded. In our experience, 66% of patients reported a satisfactory analgesic effect. The adverse effect rate was 43%; 54% of patients discontinued tapentadol therapy, i.e. 37% due to adverse effects, 15% because of inadequate pain management, and 2% because of a negative attitude of their primary care physician. Our study confi rmed the effi cacy of pain management with tapentadol. The total adverse effect rate was comparable to reports found in the literature and was lower than with classical opioid therapy. A relatively high therapy discontinuation rate was noted primarily due to adverse effects