3 research outputs found
Multidisciplinary approach in the management of pregnancy with placenta accreta spectrum disorder - Case report
From the histopathologic perspective Placenta accreta spectrum (PAS) shows the absence of the normal intervening decidua and invasion of the placenta into the myometrium. There is placenta accreta with the chorionic villi attach directly to the surface of the myometrium in the absence of the decidual layer and placenta increta when the chorionic villi penetrate deeply into the myometrium reaching the external layer. There is also placenta percreta where the invasive chorionic villi reach and penetrate through the myometrium to uterine serosa and it is nowadays the most common reason for peripartum hysterectomy (1). Drawing the line between these subtypes is not always easy, especially in the clinical situations when the invasiveness of the placenta is not known before the delivery (2). The maternal and fetal outcomes are improved upon appropriate antepartum diagnosis and care by multidisciplinary experts with experience in PAS treatment (3). Here we present a pregnancy and multidisciplinary delivery management of a 40-year-old female, gravida V, para IV, with history of the three cesarean sections, in 36+2 weeks of gestation in a tertiary academic teaching hospital. We confirmed suspected PAS antenatally based on ultrasound and magnetic resonance imaging (MRI). Preoperative preparation included the ensuring of blood products availability, the use of arterial occlusion balloons to reduce hemorrhage, and the use of double JJ stent to prevent ureteral injuries. We performed a cesarean section with immediate uterine amputation due to severe bleeding, after which the patient fully recovered. If PAS timely suspected and confirmed intraoperatively, the best maternal and neonatal outcome is achieved by the multidisciplinary approach that enables adequate elective procedure
Parkland formula role in treatment of severe burn ā Case report
Cilj je ovog rada prikaz bolesnika s iznimno opsežnim opeklinama svih dijelova tijela. MuÅ”karac srednjih godina 12-ak sati prije poÄetka bolniÄkog lijeÄenja u KBC-u Split pokuÅ”ao je suicid paljenjem plinske boce u zatvorenom prostoru, oko 150 kilometara od ustanove gdje je zapoÄeto lijeÄenje. Eksplozija i požar kojima je pacijent bio izložen uzrokovali su opekline visokog stupnja na velikoj tjelesnoj povrÅ”ini. U trenutku prijma na bolniÄko lijeÄenje pacijent je bio ekstremno agresivan i nesuradljiv. Važno je naglasiti da pacijent u trenutku prijma na bolniÄko lijeÄenje nije imao uspostavljen venski put. U bolnicu je primljen sa znatnom odgodom (12 sati +/- 1 sat), koja je produbila dehidraciju i pogorÅ”ala njegovo, veÄ ionako životno ugroženo stanje. Dubina opeklina
procijenjena je na stupnjeve II. b i III., a zahvaÄale su 70% ukupne povrÅ”ine tijela (engl. Body surface area ā BSA). Prvi cilj prije volumne nadoknade bila je uspostava odgovarajuÄega venskog puta, koji pacijent u trenutku prijma u bolnicu nije imao. Zbog agitiranosti i agresivnosti intramuskularno se injicirala kombinacija midazolama, ketamina
i atropina, a srediŔnji venski pristup uspostavio se tek kad je pacijent bio anesteziran. Obilna nadoknada kristaloidima za vrijeme inicijalnoga trosatnog zbrinjavanja privremeno je stabilizirala bolesnika, a agresivna
nadoknada kristaloidima i koloidima nastavljena je u jedinici intenzivnog lijeÄenja. Potrebe za kristaloidima u prva 24 sata izraÄunane su s pomoÄu Parklandske formule i iznosile su 25.200 mL kristaloida. Tijekom lijeÄenja pacijent je Å”est puta podvrgnut kirurÅ”kim zahvatima uz svakodnevna previjanja u opÄoj anesteziji. Boravak se zakomplicirao
zbog infekcije multirezistentnim Acinetobacter baumannii. ZakljuÄno, Parklandska formula ostaje okosnica volumne nadoknade pacijenata s opeklinama II. i III. stupnja. Odgoda lijeÄenja, prisutna u ovom sluÄaju, rezultirala je enormnom dehidracijom i gubitkom intravaskularnog volumena sa svim patofizioloÅ”kim poremeÄajima pridruženima takvom stanju. Zbrinjavanje pacijenta bilo je dodatno otežano zbog njegove agresivnosti pri prijmu, nedostatka venskog puta i nemoguÄnosti zapoÄinjanja lijeÄenja odmah ili vrlo brzo nakon nastalih opeklina.In this case report a rarely seen and a fairly demanding patient is presented. A middle-aged male with severe and extensive burns sustained after attempted suicide with ignited propane butane containing gas bottle was transported to the emergency department of University Hospital Centre Split after more than 12 hours since initial injury. Explosion and fire caused the second and third degree burns to the patient on a very large body surface area (70 percent). At the moment of admission, he was extremely aggressive, combative and uncooperative. Also, it is important to emphasize that the patient had no intravenous access. Due to the absence of intravenous access, and due to the patientsā condition, the author decided to apply midazolam, ketamine and atropine intramuscularly. After the patient was in general anaesthesia, central venous access was established via left subclavian
vein, and immediate crystalloid infusion therapy was initiated. According Parkland formula, volume of crystalloid replacement should be 25200 mL during the first 24 hours. Since more than eight hours passed from
the time of the injury, fluid deficit was theoretically more than 8400 mL. During the initial treatment and three hour surgery, the patient received 5500 mL of Plasma-Lyte solution. He was treated in the intensive care unit for a prolonged period of time, and complicated with multiresistant Acinetobacter baumannii infection. Finally, Parkland formula remains the basic tool in burn fluid resuscitation. Our intention was to present an interesting case of a middle-aged patient with extensive burns, whose care was complicated with aggression at admission, lack of
intravenous access, and a prolonged period between the initial injury and the start of hospital treatment. These greatly complicate the treatment, patientsā recovery and overall morbidity and mortality
Multidisciplinary approach in the management of pregnancy with placenta accreta spectrum disorder - Case report
From the histopathologic perspective Placenta accreta spectrum (PAS) shows the absence of the normal intervening decidua and invasion of the placenta into the myometrium. There is placenta accreta with the chorionic villi attach directly to the surface of the myometrium in the absence of the decidual layer and placenta increta when the chorionic villi penetrate deeply into the myometrium reaching the external layer. There is also placenta percreta where the invasive chorionic villi reach and penetrate through the myometrium to uterine serosa and it is nowadays the most common reason for peripartum hysterectomy (1). Drawing the line between these subtypes is not always easy, especially in the clinical situations when the invasiveness of the placenta is not known before the delivery (2). The maternal and fetal outcomes are improved upon appropriate antepartum diagnosis and care by multidisciplinary experts with experience in PAS treatment (3). Here we present a pregnancy and multidisciplinary delivery management of a 40-year-old female, gravida V, para IV, with history of the three cesarean sections, in 36+2 weeks of gestation in a tertiary academic teaching hospital. We confirmed suspected PAS antenatally based on ultrasound and magnetic resonance imaging (MRI). Preoperative preparation included the ensuring of blood products availability, the use of arterial occlusion balloons to reduce hemorrhage, and the use of double JJ stent to prevent ureteral injuries. We performed a cesarean section with immediate uterine amputation due to severe bleeding, after which the patient fully recovered. If PAS timely suspected and confirmed intraoperatively, the best maternal and neonatal outcome is achieved by the multidisciplinary approach that enables adequate elective procedure