Thoracic combined spinal-epidural anesthesia for laparoscopic cholecystectomy in an obese patient with asthma and multiple drug allergies: a case report

Drug allergies, asthma, and obesity are more common in modern societies, and patients with these problems are often a challenge for anesthetists. Different techniques of regional anesthesia can be beneficial particularly for this group of patients. We present a patient who suffered from all of the above-mentioned conditions and successfully underwent laparoscopic cholecystectomy under thoracic combined spinal-epidural anesthesia. It is still not a popular practice, and we would like to show another indication for using it

Tomografia impedancyjna w diagnostyce i monitorowaniu zaburzeń funkcji płuc na oddziale intensywnej terapii — opis przypadku i przegląd piśmiennictwa

  The aim of this paper is to describe the possibility of using Electrical Impedance Tomography (EIT) as a treatment monitoring tool in the ICU. It was based on case report and literature review. A 19-year-old female was admitted to ICU due to severe acute respiratory distress syndrome. Despite aggressive treatment there was no improvement. We decided to use EIT in the monitoring of treatment because of difficulties in transporting the patient to the radiology department in order to perform a control CT scan. After identifying the causing factor (Pneumocyctis jiroveci), EIT monitoring was maintained to assess the effectiveness of targeted microbial treatment. In the following days, we observed an improvement of regional ventilation of the upper and middle segments of the left lung that corresponded well with laboratory test results, especially arterial blood gas analysis. The use of Electrical Impedance Tomography enables non-invasive, bedside, continuous assessment of regional lung ventilation. It is possible to use it in both mechanically ventilated and spontaneously breathing patients. It allows efficient and dynamic monitoring of the course of the therapeutic process. Interpretation of the results is relatively easy to learn and does not require specialist knowledge. Moreover, it is possible to use EIT in those cases where other methods are of high risk or contraindicated.    The aim of this paper is to describe the possibility of using Electrical Impedance Tomography (EIT) as a treatment monitoring tool in the ICU. It was based on case report and literature review. A 19-year-old female was admitted to ICU due to severe acute respiratory distress syndrome. Despite aggressive treatment there was no improvement. We decided to use EIT in the monitoring of treatment because of difficulties in transporting the patient to the radiology department in order to perform a control CT scan. After identifying the causing factor (Pneumocyctis jiroveci), EIT monitoring was maintained to assess the effectiveness of targeted microbial treatment. In the following days, we observed an improvement of regional ventilation of the upper and middle segments of the left lung that corresponded well with laboratory test results, especially arterial blood gas analysis. The use of Electrical Impedance Tomography enables non-invasive, bedside, continuous assessment of regional lung ventilation. It is possible to use it in both mechanically ventilated and spontaneously breathing patients. It allows efficient and dynamic monitoring of the course of the therapeutic process. Interpretation of the results is relatively easy to learn and does not require specialist knowledge. Moreover, it is possible to use EIT in those cases where other methods are of high risk or contraindicated.

Effect of dexmedetomidine or propofol sedation on haemodynamic stability of patients after thoracic surgery

Background: Dexmedetomidine and propofol are commonly used sedative agents in non-invasive ventilation as they allow for easy arousal and are relatively well controllable. Moreover dexmedetomidine is associated with low risk of respiratory depression. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the influence of both drugs on hemodynamic effects in patients after thoracic surgical procedures receiving dexmedetomidine or propofol for noninvasive postoperative ventilation. Methods: A prospective, randomised, observational study University Hospital. Interventions: Continuous sedation with dexmedetomidine or propofol for six hours of postoperative non-invasive ventilation after thoracic surgery, with concomitant use of continuous epidural analgesia. Results: A total of 38 patients (20 dexmedetomidine and 18 propofol) were included in the analysis. The primary outcomes of this study is that heart rate, systolic and mean arterial blood pressure did not differ significantly between the groups, but diastolic arterial blood pressure was significantly higher in propofol group. Comparison analysis of epinephrine usage did not reveal significant differences between the groups. Cardiac output (CO) and cardiac index (CI) analysis did not show significant differences between the groups, but there is a clear tendency of lower values of CO/CI in group receiving propofol. We also observed similar tendency in stroke volume index (SVI) and stroke volume variation (SVV) values, but also those differences did not reach statistical significance. Systemic vascular resistance index (SVRI) values were higher in propofol group, exceeding reference values, but similarly, the difference between the groups was not significant. Conclusions: The main finding of this study is that dexmedetomidine and propofol provide similar advantages in haemodynamic stability during short-term sedation for non-invasive ventilation after thoracic surgical procedures in patients receiving continuous epidural analgesia.Background: Dexmedetomidine and propofol are commonly used sedative agents in non-invasive ventilation as they allow for straightforward arousal and are easily controllable to a relative degree. Moreover, dexmedetomidine is associated with a low risk of respiratory depression. However, both agents are associated with significant haemodynamic side effects. The primary aim of this study is to compare the influence of both drugs on haemodynamic effects in patients after thoracic surgical procedures receiving dexmedetomidine or propofol for non-invasive postoperative ventilation. Methods: A prospective, randomised, observational study conducted in a university hospital. Interventions: Continuous sedation with dexmedetomidine or propofol for six hours of postoperative non-invasive ventilation after thoracic surgery, with concomitant use of continuous epidural analgesia. Results: A total of 38 patients (20 on dexmedetomidine and 18 on propofol) were included in the analysis. The primary findings of this study were that although the heart rate, along with the systolic and mean arterial blood pressure did not differ significantly between the groups (P = 0.87; P = 0.42; P = 0.13, respectively), diastolic arterial blood pressure was significantly higher in the propofol group (P = 0.02). A comparative analysis of epinephrine usage did not reveal significant differences between the groups. Although cardiac output (P = 0.36) and cardiac index (P = 0.36) analyses did not show significant differences between the groups, there is a clear tendency toward lower values of CO/CI in the group receiving propofol. While we also observed a similar tendency in the stroke volume index and stroke volume variation values, these differences did not reach statistical significance either (P = 0.16; P = 0.64, respectively). Despite systemic vascular resistance index values being higher in the propofol group, exceeding reference values, similarly, the difference between the groups was not significant (P = 0.36). Conclusions: The main finding of this study is that dexmedetomidine and propofol provide similar advantages in haemodynamic stability during short-term sedation for non-invasive ventilation after thoracic surgical procedures in patients receiving continuous epidural analgesia

Thyromental height test as a new method for prediction of difficult intubation with double lumen tube.

BACKGROUND:Predicting difficult intubation is of high clinical interest. METHODS:237 patients aged ≥18 years were included in the study. Preoperative airway evaluation included: Mallampati test, thyromental distance, sternomental distance and thyromental height test. During direct laryngoscopy Cormack & Lehane classification was graded. We calculated the ROC AUC, sensitivity and specificity for thyromental height test as a primary end point of our study. RESULTS:Only thyromental height test and Cormack-Lehane scale proved significant on occurrence of difficult intubation. The optimal sensitivity and specificity values of thyromental height test were met with a cut off value of 50 mm. With 1 mm increase in thyromental height test, risk of difficult intubation decreased by 7%. CONCLUSION:Thyromental height test is a simple, easy to perform and non-invasive test to predict difficult intubation in patients scheduled for elective double lumen tube intubation during thoracic surgical procedures. With 1 mm above 50 mm increase in thyromental height test the risk of difficult intubation decreased by 7%. TRIAL REGISTRATION:Clinicaltrials.gov Identifier: NCT02988336

Analiza protokołów wewnątrzszpitalnego nagłego zatrzymania krążenia

Background: In-hospital sudden cardiac arrest (SCA) is an event that is linked to high mortality. Data analysis of SCA and the course of in-hospital cardiopulmonary resuscitation (CPR) allows for its better understanding and improvement. Aim: Analysis of cases of SCA and the procedures taken by the medical staff of University Hospital. Methods: A retrospective analysis of 104 protocols of SCA, from May 2014 to December 2015. Actions taken by medical staff before the arrival of the resuscitation team (RT) and RT proceedings. Data are presented as median and mean ± standard deviation. Results: 52.88% of cases were women, and their mean age was 70.82 ± 13.32 years. Resuscitation activities (basic life support: 48.08%, advance life support: 42.31%) were performed before the RT arrival, and no action was taken in 5.77% of cases. The cardiac arrest occurred most commonly in the afternoons hours, and the Emergency Room was the place of CPR in 41.35% of cases. The waiting time for RT was on average 4.47 ± 5.85 min. Non-defibrillation rhythms occurred in 79.80%, and the efficacy of resuscitation was 40%. Conclusions: Resuscitation protocols should be registered not only as an important part of medical records, but also as a source of information during the CPR training of staff. The lack of rescue activities before the arrival of the RT indicates the urgent need to identify the cause of the problem and eliminate these negative behaviours.Wstęp: Wewnątrzszpitalne nagłe zatrzymanie krążenia (SCA) jest zdarzeniem, które wiąże się dużą śmiertelnością. Analiza danych dotyczących wewnątrzszpitalnego SCA i przebiegu resuscytacji krążeniowo-oddechowej pozwala na identyfikację oraz eliminację najważniejszych czynników wpływających na przeżywalność pacjentów. Cel: Celem pracy była analiza przypadków SCA i czynności podjętych przez personel medyczny jednego ze szpitali klinicznych. Metody: Badanie miało charakter retrospektywnej analizy 104 protokołów wewnątrzszpitalnego SCA. W analizie uwzględniono czynności podjęte przez personel medyczny przed przybyciem zespołu resuscytacyjnego oraz jego postępowania. Wyniki zostały przedstawione jak mediany lub średnie ± odchylenie standardowe. Analizę statystyczną wykonano za pomocą pakietu Statistica 12. Za istotny przyjęto wynik p < 0,05. Wyniki: Analiza danych uzyskanych z protokołów SCA wykazała, że 52,88% przypadków SCA dotyczyło kobiet, średnia wieku wynosiła 70,82 ± 13,32 roku. Przed przybyciem zespołu resuscytacyjnego zostały podjęte czynności resuscytacyjne (BLS: 48,08%, ALS: 42,31%), a w 5,77% przypadków nie podjęto żadnych czynności. Znamiennie częściej SCA występowało w godzinach dopołudniowych, a Główna Izba Przyjęć w 41,35% przypadków była miejscem przeprowadzania resuscytacji krążeniowo-oddechowej. Czas oczekiwania na zespół resuscytacyjny wyniósł średnio 4,47 ± 5,85 min. Wśród wszystkich przypadków SCA rytmy nie do defibrylacji wystąpiły w 79,80%, a skuteczność przeprowadzanych resuscytacji wyniosła 40%. Wnioski: Protokoły zabiegów resuscytacyjnych należy rejestrować nie tylko jako ważną część dokumentacji medycznej, ale również jako źródło informacji prezentowanej podczas corocznych szkoleń z resuscytacji krążeniowo-oddechowej personelu szpitala. Brak podjęcia czynności ratowniczych przez część personelu szpitala przed przybyciem zespołu resuscytacyjnego wskazuje na pilną potrzebę identyfikacji przyczyn problemu i podjęcia działań zmierzających do wyeliminowania tych negatywnych zachowań