Efficiency Comparison between Nasal Cannula and Oxygen Face Mask for Oxygen Therapy during Postoperative Period

UVOD: Anestezija je povezana sa promenama ventilacije, koje počinju sa prvim datim lekom, a mogu da traju i danima posle hirurške intervencije. Hipoksemija je najočiglednija posledica ove promene. U anesteziološkoj praksi i perioperativnom tretmanu bolesnika kiseonička terapija zauzima značajno mesto. Još uvek ne postoje jasne, na dokazima zasnovane, smernice za upotrebu kiseoničke terapije u postoperativnom periodu. Razlog verovatno leži u činjenici da veliki broj faktora može da utiče na ishod lečenja hirurškog bolesnika i zato je teško ispitati njihove pojedinačne uticaje. Kiseonička terapija tretira ili prevenira nastanak hipoksije obezbeđujući inspiratornu koncentraciju kiseonika veću od iste u vazduhu. Kod najvećeg broja pacijenata u postoperativnom periodu ne postoji potreba za strogom kontrolom inspiratorne koncentracije kiseonika, a administracija kiseoničke terapije sprovodi se primenom uređaja niskog protoka i varijabilne performanse, kao što su nazalna kanila i kiseonička maska za lice. Brojna istraživanja poslednjih decenija pokušala su da daju odgovor na pitanja da li postoji stvarna razlika u primeni ova dva uređaja, posebno u svetlu razvoja hipoksemije u postoperativnom periodu. Prednosti primene nazalne kanile su bolje prihvatanje od strane bolesnika u poređenju sa maskom, obično zbog manje izraženog osećaja klaustrofobije pri upotrebi nazalne kanile. Nazalna kanila, ne zahteva uklanjanje prilikom nege usne duplje ili per os unosa što obezbeđuje kontinuitet u isporuci kiseonika. Nedostaci nazalne kanile vezani su za otežanu primenu kod bolesnika sa nazogastričnom sondom ili otežanim disanjem na nos. Pri protocima većim od 4 litre u mnuti može izazvati nelagodnost na nosnoj sluznici bolesnika. Literaturni podaci, ukazuju da se primenom kiseoničke maske ipak postižu veće inspiratorne koncentracije kiseonika, te da se epizode desaturacije i hipoksemije znatno ređe javljaju. Međutim, postoje i istraživanja koja ukazuju na mogućnost ponovnog udisanja vazduha iz mrtvog prostora maske, pri nižim protocima što može uticati na parcijalni pritisak ugljen-dioksida u arterijskoj krvi. CILJEVI: Ciljevi istraživanja su da se ispitata učestalost javljanja hipoksemije unutar 48 sati od ekstubacije kod bolesnika u jedinici intezivne terapije, zatima da se ispita pojava desaturacije, da se utvrditi učestalost potrebe za primenom neinvazivne mehaničke ventilacije pozitivnim pritiskom kod bolesnika u jedinici intezivne terapije kod kojih se primenjuje kiseonička terapija putem nazalne kanile, odnosno kiseoničke maske. Takođe, cilj je i da se ispita da li postoji povezanost preoperativnih karakteristika bolesnika sa eventualnim izborom jednog od dva uređaja za primenu kiseoničke terapije u ranom postoperativnom periodu. METODOLOGIJA: Na Klinici za anesteziju i intenzivnu terapiju Kliničkog centra Vojvodine sprovedeno je prospektivno istraživanje kojim je obuhvaćeno 160 pacijenata nakon elektivnih hrurških procedura, koji su nakon operativnog zahvata praćeni u jedinici intenzivne terapije. Pacijenti su randomizovani u dve grupe (grupa M – kiseonička maska i grupa N – nazalna kanila) u odnosu na uređaj kojim je sprovođena postoperativna kiseonička terapija. Za sve pacijente uključene u studiju evidentirana je pol, starost, telesna masa, telesna visina, izračunat indeks telesne mase. Evidentiran je i ASA status, kao i NYHA status. U istraživanje nisu uključeni pacijenti sa plućnim komorbiditetima. Iz istraživanja su isključeni svi oni bolesnici kod kojih je došlo do respiratornih komplikacija u perioperativnom periodu, kao i onih kod kojih je bila prisutna hemodinamska nestabilnost. Postoperativno svi pacijenti su sedirani, na mehaničkoj ventilaciji smešteni u jedinicu intenzivne terapije. Nakon prevođenja na spontano disanje i ekstubacije započinjana je primena kiseonika putem kiseoničke maske za lice (6 l/min) odnosno nazalne kanile (4 l/min). Sprovođen je kontinuirani monitoring vitalnih parametara, saturacije hemoglobina kiseonikom, kao i novo ugljen-dioksida na kraju ekspirijuma. Kod svih pacijenata u četiri vremena rađene su gasne analize arterijske krvi. Svi praćeni parametri poređeni su između dve ispitivane grupe pacijenata. Za statističku obradu podataka korišćen je programski paket Statistical Package for Social Sciences - SPSS 21. Numerička obeležja su prikazana putem srednjih vrednosti (aritmetička sredina) i mera varijabiliteta (opseg vrednosti, standardna devijacija), a atributivna obeležja korišćenjem frekvencija i procenata. Komparacija vrednosti numeričkih obeležja između dve grupe vršena je primenom Studentovog t- testa, odnosno neparametrijskog Mann- Whitney testa. Testiranje razlike frekvencija atributivnih obeležja vršeno je primenom χ2 testa. U cilju ispitivanja povezanosti dva ili više obeležja, odnosno generisanja adekvatnih statističkih modela, korišćena je multivarijantna regresiona analiza. Statistički značajnim se smatraju vrednosti nivoa značajnosti p<0.05. REZULTATI: U odnosu na preoperativne karakteristike ispitivanih pacijenata nije nađena statistički značajna razlika u distribuciji pacijenata u dve ispitivane grupe u odnosu na pol (2 test; 2=0,378;p=0,539), starost (T test; t=1,958; p=0,053), APACHE II skor na prijemu (Mann-Whitney test; U=1220,500; p=0,837), indeks telesne mase (T test; t=1,380; p=0,171), pušačkim navikama (2 test; 2=0,644;p=0,422), vrednostima preoperativnog hemoglobina (T test; t=0,442; p=0,660), saturacije hemoglobina kiseonikom (T test; t=0,883; p=0,380). Razlike nije bilo ni u pogledu trajanja mehaničke ventilacije (Mann-Whitney test; U=1114,500; p=0,345). Hipoksemija (parcijalni pritisak kiseonika u arterijskoj krvi manji od 65 mmHg) nije registrovana ni kod jednog od pacijenata u obe ispitivane grupe. Vrednsti SpO2 < 92%, registrovane su kod ukupno 24 pacijenta u svim analiziranim vremenima (24%). Najveći broj pacijenata kod kojih je registrovana niska vrednost detektovan je u prvom satu nakon ekstubacije kada je vrednost manja od 92% registrovana kod 5 pacijenata (5%) i to kod 3 pacijenta u grupi M (6%) i 2 pacijenta u grupi N (4%). Između vizita 2. i 3. vrednosti satutracije manje od 92% registrovana je kod 19 pacijenata (19%), kod 8 pacijenata u grupi M (16%) i kod 11 pacijenata u grupi N (22%). U periodu između vizita 3. i 4. vrednosti saturacije niže od 92% registrovane su kod 19 (19%) pacijenata i to kod 10 pacijenata u grupi M (20%) i kod 9 pacijenata u grupi N (18%). Statistički značajna razlika zabeležena je u sve tri vizite (vizita 2, 3, 4) u vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi. Tako su pacijenti u grupi kod kojih je primenjivana maska imali statistički značajno veće vrednosti parcijalnog pritiska kiseonika. Istovremeno pacijenti kod kojih je kiseonička terapija primenjivana putem maske imali su značajno veće vrednosti saturacije hemoglobina kiseonikom i ova razlika je bila statistički značajna u svim posmatranim vizitama. U prvih 48 sati nakon operacije neinvazivna mehanička ventilacija primenjena je kod 80 pacijenata. Kod svih pacijenata indikacija za primenu je bila pojava desaturacije. U odnosu na distribuciju pacijenata po ispitivanim grupama nije bilo statistički značajne razlike u broju pacijenata koji su zahtevali neinvazivnu mehaničku ventilaciju (2 test; 2=2,250; p=0,134). Pacijenti u grupi N proveli su više minuta (srednja vrednost 56,85 +/- 19,80 minuta) na neinvazivnoj ventilaciji od pacijenata u grupi M (srednja vrednost 33,14 +/- 10,65 minuta), a ova razlika je statistički značajna (T test; t=2,923; p=0,009). Na osnovu multivarijantne regresione analize, pacijenti koji su kiseoničku terapiju primali putem nazalne kanile, sa porastom indeksa telesne mase imali su niže vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi (r2=0,392). ZAKLJUČCI: Kiseonička maska za lice i nazalna kanila obezbeđuju adekvatnu primenu kiseoničke terapije u smislu prevencije nastanka hipoksemije u ranom postoperativnom periodu. Primenom kiseoničke maske za lice ostvaruju se više vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi. Epizode desaturacije češće se javljaju kod pacijenata kod kojih se u ranom postoperativnom periodu primenjuje kiseonička terapija putem nazalne kanile. Pacijenti kod kojih se primenjuje kiseonička terapija putem maske ostvaruju veće vrednosti saturacije hemoglobina kiseonikom. Pacijenti kod kojih je kiseonička terapija u ranom postoperativnom periodu primenjivana putem nazalne kanile zahtevali su dužu primenu neinvazivne mehaničke ventilacije pluća. Kod pacijenata sa većim vrednostima indeksa telesne mase, za primenu kiseoničke terapije u ranom postoperativnom periodu, kiseonička maska za lice će obezbediti bolju oksigenaciju.INTRODUCTION: Anesthesiology is associated with vicissitudes in ventilation, which start with application of first medicine and last for days following surgical intervention. Hypoxemia is a most common side effect of vicissitudes in ventilation. Oxygen therapy is important in anesthesiology and post-operative treatment of a patient. There are no clear evidence-based guidelines for application of oxygen therapy in post-operative period. Numerous factors influence patient’s treatment outcome and it is difficult to examine each factor’s independent impact. Oxygen therapy treats or prevents occurrence of hypoxemia by providing inspiratory concentration of oxygen greater than the amount found in air. Most patients in post-operative period don’t require vigilant control of inspiratory concentration of oxygen, and administration of oxygen therapy is implemented with a low flow device with variable performances such as nasal cannula and oxygen face mask. Various research attempts where made in the last decades to discover an evident difference between these two devices, especially in cases where hypoxemia occurred in post-operative period. One advantage to using nasal cannula over oxygen face mask is that its better perceived by a patient as it reduces feeling of claustrophobia. Nasal cannula doesn’t need to be removed during oral cavity care or “per os” intake which ensures continuous oxygen delivery. The drawback to using nasal cannula is that its challenging to insert it in a patient with nasogastric tube or difficult nasal breathing. Also, patient can experience nasal discomfort if the oxygen flow is bigger than four litters per minute. Literature data shows that application of oxygen trough the face mask achieves greater inspiratory concentrations of oxygen, and reduces the occurrence of desaturation and hypoxemia. Still, there is research which points out to the possibility of breathing in from dead space in the mask, in lower flows, which can partially affect pressure of carbon dioxide in artery blood. AIM: Aim of the research is to examine frequency of hypoxemia and non-invasive mechanical ventilation in patients treated with oxygen therapy via nasal cannula or oxygen face mask during the first 48 hours following patient extubating in intensive care unit. Also, aim is to examine correlation between patients’ pre-operative characteristics and the choice of one of the two devices for oxygen therapy in early postoperative period. METHODOLOGY: Clinic for Anesthesiology and Intensive Therapy at the Clinical Center of Vojvodina conducted this research on 160 patients who underwent elective surgical procedures and received post-operative care in Intensive Care Unit. Patients were randomly assigned to two groups (Group M with oxygen face mask and Group N with nasal cannula) relative to device which was used for post-operative oxygen therapy. Information recorded for all the patients included in the study constituted their gender, age, weight, hight, and body max index. ASA status, as well as NYHA status were also recorded. Research excluded any patient who experienced respiratory complications in post-operative period as well as those who experienced hemodynamic instability. Postoperatively all patients were sedated and on mechanical ventilation therapy in intensive care unit. After transition to spontaneous breathing and extubating, oxygen therapy was applied using oxygen mask (6 l/min) or nasal cannula (4 l/min). Vital parameters were continuously monitored as well as hemoglobin oxygen saturation, and carbon dioxide at the end of the expirium. Gas analysis of artery blood was carried out four times for all participants in the study. All parameters were compared between two examined patient groups. Statistical analysis was carried out using Statistical Package for Social Sciences - SPSS 21. Numerical features are depicted using arithmetic mean and variability rate, and attributive features are depicted with frequency and percentages. Comparison of the values of numerical characteristics between the two groups was performed using Student's t-test, that is, a non-parametric Mann-Whitney test. The frequency difference in attributive characteristics was tested using χ2 test. To generate adequate statistical model, multivariate regression analysis was applied to examine the link between two or more of features. Significant values are determined if level of significance is p<0.05. RESULTS: Preoperative characteristics of the patient showed no significant differences between the two study groups. Characteristics were recorded with respect to gender (2 test; 2 = 0.378; p = 0.539), age (t-test; t = 1,958, p = 0,053 ), APACHE II score on admission (Mann-Whitney test; U = 1220.500; p = 0.837), body mass index (t-test; t = 1.380, p = 0.171), smoking habits (2 test; 2 = 0.644; p = 0.422), the values of the preoperative hemoglobin (t-test; t = 0.442, p = 0.660), and hemoglobin oxygen saturation (t-test; t = 0.883, p = 0.380). Difference was discovered in regards to duration of mechanical ventilation (Mann-Whitney test; U = 1114.500; p = 0.345). Hypoxemia (partial oxygen pressure in the arterial blood of less than 65 mmHg) was not registered in any of the patients in both study groups. Value SpO2< 92%, was registered in 24 patients during every round (24%). Patients who registered value lower than 92% experienced it in the first hour post extubation. This was observed in 5 patients in total (5%) where 3 patients from group M (6%) and 2 from group N (4%). Between 2nd and 3rd rounds, saturation values lower than 92% were recorded in 19 patients (19%): 8 from group M (16%) and 11 from group N (22%). In the period between the 3rd and 4th rounds the value of saturation lower than 92% was detected in 19 (19%) patients: 10 from group M (20%) and 9 from group N (18%). Statistically significant difference was noted in all three rounds (rounds 2, 3, 4) in the values of the partial oxygen pressure in arterial blood. Thus, patients from the group treated with an oxygen face mask had significantly higher values of partial oxygen pressure. In addition patients treated by oxygen face mask had significantly higher levels of oxygen saturated hemoglobin, and this difference was statistically significant in all observed rounds. In the first 48 hours after surgery noninvasive mechanical ventilation was performed in 80 patients. Common indication for oxygen therapy in all patients was desaturation. There were no statistically significant differences in the number of patients who required non-invasive mechanical ventilation in either of the groups (2 test; 2 = 2.250; p = 0.134). Patients in group N received several minutes more (mean value of 56.85 +/- 19.80 minutes) of the non-invasive ventilation than patients in the group M (mean value of 33.14 +/- 10.65 minutes), and this difference was statistically significant (t-test; t = 2,923, p = 0,009). Based on the multivariate regression analysis, the patients who received oxygen therapy via nasal cannula, with the increase in body mass index had lower values of partial oxygen pressure in arterial blood (r2 = 0.392). CONCLUSION: Both face mask and nasal cannula ensure adequate application of oxygen therapy to prevent hypoxemia in the early postoperative period. Oxygen face mask achieves higher value of partial oxygen pressure in arterial blood. Episodes of desaturation more frequently occur in patients who receive oxygen therapy with nasal cannula in early postoperative period. Patients who receive oxygen therapy via oxygen face mask achieve higher hemoglobin oxygen saturation values. Patients who undergo oxygen therapy in the early postoperative period using nasal cannula require longer application of non-invasive mechanical ventilation. Patients with higher body mass index receive better oxygenation in the early postoperative period if facial mask is the device of choice

Efficiency Comparison between Nasal Cannula and Oxygen Face Mask for Oxygen Therapy during Postoperative Period

UVOD: Anestezija je povezana sa promenama ventilacije, koje počinju sa prvim datim lekom, a mogu da traju i danima posle hirurške intervencije. Hipoksemija je najočiglednija posledica ove promene. U anesteziološkoj praksi i perioperativnom tretmanu bolesnika kiseonička terapija zauzima značajno mesto. Još uvek ne postoje jasne, na dokazima zasnovane, smernice za upotrebu kiseoničke terapije u postoperativnom periodu. Razlog verovatno leži u činjenici da veliki broj faktora može da utiče na ishod lečenja hirurškog bolesnika i zato je teško ispitati njihove pojedinačne uticaje. Kiseonička terapija tretira ili prevenira nastanak hipoksije obezbeđujući inspiratornu koncentraciju kiseonika veću od iste u vazduhu. Kod najvećeg broja pacijenata u postoperativnom periodu ne postoji potreba za strogom kontrolom inspiratorne koncentracije kiseonika, a administracija kiseoničke terapije sprovodi se primenom uređaja niskog protoka i varijabilne performanse, kao što su nazalna kanila i kiseonička maska za lice. Brojna istraživanja poslednjih decenija pokušala su da daju odgovor na pitanja da li postoji stvarna razlika u primeni ova dva uređaja, posebno u svetlu razvoja hipoksemije u postoperativnom periodu. Prednosti primene nazalne kanile su bolje prihvatanje od strane bolesnika u poređenju sa maskom, obično zbog manje izraženog osećaja klaustrofobije pri upotrebi nazalne kanile. Nazalna kanila, ne zahteva uklanjanje prilikom nege usne duplje ili per os unosa što obezbeđuje kontinuitet u isporuci kiseonika. Nedostaci nazalne kanile vezani su za otežanu primenu kod bolesnika sa nazogastričnom sondom ili otežanim disanjem na nos. Pri protocima većim od 4 litre u mnuti može izazvati nelagodnost na nosnoj sluznici bolesnika. Literaturni podaci, ukazuju da se primenom kiseoničke maske ipak postižu veće inspiratorne koncentracije kiseonika, te da se epizode desaturacije i hipoksemije znatno ređe javljaju. Međutim, postoje i istraživanja koja ukazuju na mogućnost ponovnog udisanja vazduha iz mrtvog prostora maske, pri nižim protocima što može uticati na parcijalni pritisak ugljen-dioksida u arterijskoj krvi. CILJEVI: Ciljevi istraživanja su da se ispitata učestalost javljanja hipoksemije unutar 48 sati od ekstubacije kod bolesnika u jedinici intezivne terapije, zatima da se ispita pojava desaturacije, da se utvrditi učestalost potrebe za primenom neinvazivne mehaničke ventilacije pozitivnim pritiskom kod bolesnika u jedinici intezivne terapije kod kojih se primenjuje kiseonička terapija putem nazalne kanile, odnosno kiseoničke maske. Takođe, cilj je i da se ispita da li postoji povezanost preoperativnih karakteristika bolesnika sa eventualnim izborom jednog od dva uređaja za primenu kiseoničke terapije u ranom postoperativnom periodu. METODOLOGIJA: Na Klinici za anesteziju i intenzivnu terapiju Kliničkog centra Vojvodine sprovedeno je prospektivno istraživanje kojim je obuhvaćeno 160 pacijenata nakon elektivnih hrurških procedura, koji su nakon operativnog zahvata praćeni u jedinici intenzivne terapije. Pacijenti su randomizovani u dve grupe (grupa M – kiseonička maska i grupa N – nazalna kanila) u odnosu na uređaj kojim je sprovođena postoperativna kiseonička terapija. Za sve pacijente uključene u studiju evidentirana je pol, starost, telesna masa, telesna visina, izračunat indeks telesne mase. Evidentiran je i ASA status, kao i NYHA status. U istraživanje nisu uključeni pacijenti sa plućnim komorbiditetima. Iz istraživanja su isključeni svi oni bolesnici kod kojih je došlo do respiratornih komplikacija u perioperativnom periodu, kao i onih kod kojih je bila prisutna hemodinamska nestabilnost. Postoperativno svi pacijenti su sedirani, na mehaničkoj ventilaciji smešteni u jedinicu intenzivne terapije. Nakon prevođenja na spontano disanje i ekstubacije započinjana je primena kiseonika putem kiseoničke maske za lice (6 l/min) odnosno nazalne kanile (4 l/min). Sprovođen je kontinuirani monitoring vitalnih parametara, saturacije hemoglobina kiseonikom, kao i novo ugljen-dioksida na kraju ekspirijuma. Kod svih pacijenata u četiri vremena rađene su gasne analize arterijske krvi. Svi praćeni parametri poređeni su između dve ispitivane grupe pacijenata. Za statističku obradu podataka korišćen je programski paket Statistical Package for Social Sciences - SPSS 21. Numerička obeležja su prikazana putem srednjih vrednosti (aritmetička sredina) i mera varijabiliteta (opseg vrednosti, standardna devijacija), a atributivna obeležja korišćenjem frekvencija i procenata. Komparacija vrednosti numeričkih obeležja između dve grupe vršena je primenom Studentovog t- testa, odnosno neparametrijskog Mann- Whitney testa. Testiranje razlike frekvencija atributivnih obeležja vršeno je primenom χ2 testa. U cilju ispitivanja povezanosti dva ili više obeležja, odnosno generisanja adekvatnih statističkih modela, korišćena je multivarijantna regresiona analiza. Statistički značajnim se smatraju vrednosti nivoa značajnosti p<0.05. REZULTATI: U odnosu na preoperativne karakteristike ispitivanih pacijenata nije nađena statistički značajna razlika u distribuciji pacijenata u dve ispitivane grupe u odnosu na pol (2 test; 2=0,378;p=0,539), starost (T test; t=1,958; p=0,053), APACHE II skor na prijemu (Mann-Whitney test; U=1220,500; p=0,837), indeks telesne mase (T test; t=1,380; p=0,171), pušačkim navikama (2 test; 2=0,644;p=0,422), vrednostima preoperativnog hemoglobina (T test; t=0,442; p=0,660), saturacije hemoglobina kiseonikom (T test; t=0,883; p=0,380). Razlike nije bilo ni u pogledu trajanja mehaničke ventilacije (Mann-Whitney test; U=1114,500; p=0,345). Hipoksemija (parcijalni pritisak kiseonika u arterijskoj krvi manji od 65 mmHg) nije registrovana ni kod jednog od pacijenata u obe ispitivane grupe. Vrednsti SpO2 < 92%, registrovane su kod ukupno 24 pacijenta u svim analiziranim vremenima (24%). Najveći broj pacijenata kod kojih je registrovana niska vrednost detektovan je u prvom satu nakon ekstubacije kada je vrednost manja od 92% registrovana kod 5 pacijenata (5%) i to kod 3 pacijenta u grupi M (6%) i 2 pacijenta u grupi N (4%). Između vizita 2. i 3. vrednosti satutracije manje od 92% registrovana je kod 19 pacijenata (19%), kod 8 pacijenata u grupi M (16%) i kod 11 pacijenata u grupi N (22%). U periodu između vizita 3. i 4. vrednosti saturacije niže od 92% registrovane su kod 19 (19%) pacijenata i to kod 10 pacijenata u grupi M (20%) i kod 9 pacijenata u grupi N (18%). Statistički značajna razlika zabeležena je u sve tri vizite (vizita 2, 3, 4) u vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi. Tako su pacijenti u grupi kod kojih je primenjivana maska imali statistički značajno veće vrednosti parcijalnog pritiska kiseonika. Istovremeno pacijenti kod kojih je kiseonička terapija primenjivana putem maske imali su značajno veće vrednosti saturacije hemoglobina kiseonikom i ova razlika je bila statistički značajna u svim posmatranim vizitama. U prvih 48 sati nakon operacije neinvazivna mehanička ventilacija primenjena je kod 80 pacijenata. Kod svih pacijenata indikacija za primenu je bila pojava desaturacije. U odnosu na distribuciju pacijenata po ispitivanim grupama nije bilo statistički značajne razlike u broju pacijenata koji su zahtevali neinvazivnu mehaničku ventilaciju (2 test; 2=2,250; p=0,134). Pacijenti u grupi N proveli su više minuta (srednja vrednost 56,85 +/- 19,80 minuta) na neinvazivnoj ventilaciji od pacijenata u grupi M (srednja vrednost 33,14 +/- 10,65 minuta), a ova razlika je statistički značajna (T test; t=2,923; p=0,009). Na osnovu multivarijantne regresione analize, pacijenti koji su kiseoničku terapiju primali putem nazalne kanile, sa porastom indeksa telesne mase imali su niže vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi (r2=0,392). ZAKLJUČCI: Kiseonička maska za lice i nazalna kanila obezbeđuju adekvatnu primenu kiseoničke terapije u smislu prevencije nastanka hipoksemije u ranom postoperativnom periodu. Primenom kiseoničke maske za lice ostvaruju se više vrednosti parcijalnog pritiska kiseonika u arterijskoj krvi. Epizode desaturacije češće se javljaju kod pacijenata kod kojih se u ranom postoperativnom periodu primenjuje kiseonička terapija putem nazalne kanile. Pacijenti kod kojih se primenjuje kiseonička terapija putem maske ostvaruju veće vrednosti saturacije hemoglobina kiseonikom. Pacijenti kod kojih je kiseonička terapija u ranom postoperativnom periodu primenjivana putem nazalne kanile zahtevali su dužu primenu neinvazivne mehaničke ventilacije pluća. Kod pacijenata sa većim vrednostima indeksa telesne mase, za primenu kiseoničke terapije u ranom postoperativnom periodu, kiseonička maska za lice će obezbediti bolju oksigenaciju.INTRODUCTION: Anesthesiology is associated with vicissitudes in ventilation, which start with application of first medicine and last for days following surgical intervention. Hypoxemia is a most common side effect of vicissitudes in ventilation. Oxygen therapy is important in anesthesiology and post-operative treatment of a patient. There are no clear evidence-based guidelines for application of oxygen therapy in post-operative period. Numerous factors influence patient’s treatment outcome and it is difficult to examine each factor’s independent impact. Oxygen therapy treats or prevents occurrence of hypoxemia by providing inspiratory concentration of oxygen greater than the amount found in air. Most patients in post-operative period don’t require vigilant control of inspiratory concentration of oxygen, and administration of oxygen therapy is implemented with a low flow device with variable performances such as nasal cannula and oxygen face mask. Various research attempts where made in the last decades to discover an evident difference between these two devices, especially in cases where hypoxemia occurred in post-operative period. One advantage to using nasal cannula over oxygen face mask is that its better perceived by a patient as it reduces feeling of claustrophobia. Nasal cannula doesn’t need to be removed during oral cavity care or “per os” intake which ensures continuous oxygen delivery. The drawback to using nasal cannula is that its challenging to insert it in a patient with nasogastric tube or difficult nasal breathing. Also, patient can experience nasal discomfort if the oxygen flow is bigger than four litters per minute. Literature data shows that application of oxygen trough the face mask achieves greater inspiratory concentrations of oxygen, and reduces the occurrence of desaturation and hypoxemia. Still, there is research which points out to the possibility of breathing in from dead space in the mask, in lower flows, which can partially affect pressure of carbon dioxide in artery blood. AIM: Aim of the research is to examine frequency of hypoxemia and non-invasive mechanical ventilation in patients treated with oxygen therapy via nasal cannula or oxygen face mask during the first 48 hours following patient extubating in intensive care unit. Also, aim is to examine correlation between patients’ pre-operative characteristics and the choice of one of the two devices for oxygen therapy in early postoperative period. METHODOLOGY: Clinic for Anesthesiology and Intensive Therapy at the Clinical Center of Vojvodina conducted this research on 160 patients who underwent elective surgical procedures and received post-operative care in Intensive Care Unit. Patients were randomly assigned to two groups (Group M with oxygen face mask and Group N with nasal cannula) relative to device which was used for post-operative oxygen therapy. Information recorded for all the patients included in the study constituted their gender, age, weight, hight, and body max index. ASA status, as well as NYHA status were also recorded. Research excluded any patient who experienced respiratory complications in post-operative period as well as those who experienced hemodynamic instability. Postoperatively all patients were sedated and on mechanical ventilation therapy in intensive care unit. After transition to spontaneous breathing and extubating, oxygen therapy was applied using oxygen mask (6 l/min) or nasal cannula (4 l/min). Vital parameters were continuously monitored as well as hemoglobin oxygen saturation, and carbon dioxide at the end of the expirium. Gas analysis of artery blood was carried out four times for all participants in the study. All parameters were compared between two examined patient groups. Statistical analysis was carried out using Statistical Package for Social Sciences - SPSS 21. Numerical features are depicted using arithmetic mean and variability rate, and attributive features are depicted with frequency and percentages. Comparison of the values of numerical characteristics between the two groups was performed using Student's t-test, that is, a non-parametric Mann-Whitney test. The frequency difference in attributive characteristics was tested using χ2 test. To generate adequate statistical model, multivariate regression analysis was applied to examine the link between two or more of features. Significant values are determined if level of significance is p<0.05. RESULTS: Preoperative characteristics of the patient showed no significant differences between the two study groups. Characteristics were recorded with respect to gender (2 test; 2 = 0.378; p = 0.539), age (t-test; t = 1,958, p = 0,053 ), APACHE II score on admission (Mann-Whitney test; U = 1220.500; p = 0.837), body mass index (t-test; t = 1.380, p = 0.171), smoking habits (2 test; 2 = 0.644; p = 0.422), the values of the preoperative hemoglobin (t-test; t = 0.442, p = 0.660), and hemoglobin oxygen saturation (t-test; t = 0.883, p = 0.380). Difference was discovered in regards to duration of mechanical ventilation (Mann-Whitney test; U = 1114.500; p = 0.345). Hypoxemia (partial oxygen pressure in the arterial blood of less than 65 mmHg) was not registered in any of the patients in both study groups. Value SpO2< 92%, was registered in 24 patients during every round (24%). Patients who registered value lower than 92% experienced it in the first hour post extubation. This was observed in 5 patients in total (5%) where 3 patients from group M (6%) and 2 from group N (4%). Between 2nd and 3rd rounds, saturation values lower than 92% were recorded in 19 patients (19%): 8 from group M (16%) and 11 from group N (22%). In the period between the 3rd and 4th rounds the value of saturation lower than 92% was detected in 19 (19%) patients: 10 from group M (20%) and 9 from group N (18%). Statistically significant difference was noted in all three rounds (rounds 2, 3, 4) in the values of the partial oxygen pressure in arterial blood. Thus, patients from the group treated with an oxygen face mask had significantly higher values of partial oxygen pressure. In addition patients treated by oxygen face mask had significantly higher levels of oxygen saturated hemoglobin, and this difference was statistically significant in all observed rounds. In the first 48 hours after surgery noninvasive mechanical ventilation was performed in 80 patients. Common indication for oxygen therapy in all patients was desaturation. There were no statistically significant differences in the number of patients who required non-invasive mechanical ventilation in either of the groups (2 test; 2 = 2.250; p = 0.134). Patients in group N received several minutes more (mean value of 56.85 +/- 19.80 minutes) of the non-invasive ventilation than patients in the group M (mean value of 33.14 +/- 10.65 minutes), and this difference was statistically significant (t-test; t = 2,923, p = 0,009). Based on the multivariate regression analysis, the patients who received oxygen therapy via nasal cannula, with the increase in body mass index had lower values of partial oxygen pressure in arterial blood (r2 = 0.392). CONCLUSION: Both face mask and nasal cannula ensure adequate application of oxygen therapy to prevent hypoxemia in the early postoperative period. Oxygen face mask achieves higher value of partial oxygen pressure in arterial blood. Episodes of desaturation more frequently occur in patients who receive oxygen therapy with nasal cannula in early postoperative period. Patients who receive oxygen therapy via oxygen face mask achieve higher hemoglobin oxygen saturation values. Patients who undergo oxygen therapy in the early postoperative period using nasal cannula require longer application of non-invasive mechanical ventilation. Patients with higher body mass index receive better oxygenation in the early postoperative period if facial mask is the device of choice

IZBOČENJE GORNJIH SJEKUTIĆA JE DOBAR PREDSKAZATELJ OTEŽANE INTUBACIJE

Background and aim: One of the most important goals of pre-anesthesiologic evaluation is assessment of the airway. The aim of the present study was to determine the incidence of diffi cult intubation in surgical patients, and to establish which external anatomic factors are the best predictors of diffi cult intubation. Patients and methods: This prospective observational cross-sectional study included 200 adult patients who were scheduled to receive general anesthesia with intubation for elective surgical procedures. Results: Among 200 patients, 191 (95.5%) had normal intubation and 9 (4.5%) had difficult intubation. Age, height, body mass index, upper incisor prominence and interincisor gap were independently associated with diffi cult intubation. With every year of increase in age, the odds ratio for diffi cult intubation decreased by 7%. Odds of diffi cult intubation increased by 1.143 with each additional centimeter of patient height. Patients with prominent upper incisors were nearly seven times more likely to have diffi cult intubation. The odds of diffi cult intubation decreased by 96% in patients with the interincisor gap greater than 3 cm. Conclusion: Interincisor gap of less than 3 cm is a risk factor for difficult intubation, while those patients with prominent upper incisors are seven-fold more likely to have diffi cult intubation.Uvod i cilj: Jedan od najvažnijih ciljeva predanesteziološke evaluacije je ocjena dišnog puta. Cilj ove studije bio je odrediti incidenciju otežane intubacije kod kirurških pacijenata i utvrditi koji su vanjski anatomski faktori najbolji predskazatelji otežane intubacije. Bolesnici i metode: Ova prospektivna opservacijska presječna studija uključila je 200 odraslih pacijenata koji su bili podvrgnuti općoj anesteziji s intubacijom zbog elektivnih kirurških postupaka. Rezultati: Od 200 pacijenata 191 (95,5%) imao je normalnu intubaciju, a 9 (4,5%) otežanu intubaciju. Dob, visina, indeks tjelesne mase, izbočenje gornjih sjekutića i razmak između sjekutića bili su neovisno povezani s otežanom intubacijom. Sa svakom godinom povećanja dobi odnos šanse za otežanu intubaciju bio je manji od 7%. Šansa za otežanu intubaciju povećavala se za 1,143 sa svakim dodatnim centimetrom pacijentove visine. Bolesnici s izbočenjem gornjih sjekutića gotovo su 7 puta češće imali otežanu intubaciju. Šanse za otežanu intubaciju smanjivale su se za 96 % u pacijenata s razmakom između sjekutića većim od 3 cm. Zaključak: Razmak između sjekutića manji od 3 cm je rizični faktor za otežanu intubaciju, dok je za pacijente s izbočenjem gornjih sjekutića sedam puta vjerojatnije da će imati otežanu intubaciju

Perkutana dilatacijska traheostomija u bolesnika s COVID-19 u jedinici intezivnog liječenja: iskustvo COVID bolnice Kliničkog centra Vojvodine

Patients with acute respiratory distress syndrome due to COVID-19 require intensive care unit (ICU) admission with consecutive endotracheal intubation and invasive mechanical ventilation. In patients with long-term mechanical ventilation, percutaneous dilatational tracheostomy (PDT) may be considered. This retrospective analysis includes clinical data on patients treated at the ICUs of the COVID Hospital of the Clinical Center of Vojvodina in the period from September 3, 2021 to May 1, 2022, and underwent PDT. Patients were predominantly male (n=48; 65.8%). Weaning from mechanical ventilation was achieved in 31 (42.5%) and decannulation in 25 (34.2%) patients. The mean time from polymerase chain reaction SARS CoV-2 positivity until PDT was 15.59±6.85 days. The mean time of endotracheal intubation before the PDT procedure was 7.37±4.89 days. The mean weaning time from mechanical ventilation was 10.45±7.92 days. Twenty-five (34.2%) patients were decannulated at the mean time of 19.60±11.81 days. The complications were tracheostomy related bleeding (2 patients), pneumothorax (4 patients), subcutaneous emphysema (1 patient) and cricoid cartilage injury (1 patient). PDT is a simple, safe, and effective procedure performed in COVID-19 patients in the ICU.Bolesnici sa sindromom akutnog respiracijskog distresa zbog COVID-19 zahtijevaju prijam u jedinicu intenzivnog liječanja (JIL) s posljedičnom endotrahealnom intubacijom i invazivnom mehaničkom ventilacijom. U bolesnika na produženoj mehaničkoj ventilaciji potrebno je razmotriti perkutanu dilatacijsku traheostomiju (PDT). Ova retrospektivna analiza uključuje kliničke podatke bolesnika koji su liječeni u jedinici intenzivnog liječenja u COVID bolnici Kliničkog centra Vojvodine u razdoblju od 3. rujna 2021. do 1. svibnja 2022. i koji su bili podvrgnuti PDT-u. Bolesnici su pretežito bili muškarci (n=48; 65,8%). Odvajanje od mehaničke ventilacije je postignuto u 31 (42,5%) i dekanilacija u 25 (34,5%) bolesnika. Srednje vrijeme od dokazanog pozitiviteta PCR testom na SARS CoV-2 do PDT je bilo 15,59±6,85 dana. Srednje vrijeme endotrahealne intubacije prije postupka PDT je bilo 7,37±4,89 dana. Srednje vrijeme odvajanja od mehaničke ventilacije je bilo 10,45±7,92 dana. Dekanilirano je bilo 25 (34,5%) bolesnika, a srednje vrijeme je bilo 19,60±11,81 dana. Komplikacije su bile krvarenje povezano uz traheostomu (2 bolesnika), pneumotoraks (4 bolesnika), subkutani emfizem (1 bolesnik) i ozljeda krikoidne hrskavice (1 bolesnik). PDT je jednostavan, siguran i učinkovit postupak u bolesnika s COVID-19 u JIL-u

Association between vitamin D hypovitaminosis and severe forms of COVID-19

Objective: Hypovitaminosis D may be associated with an increased susceptibility to infection, more severe COVID-19 forms, and a higher risk of death. The objective of this study was to investigate any possible connections between vitamin D status [as measured by serum 25-hydroxyvitamin D (25(OH)D) levels] and COVID-19 severity. Patients and methods: In 2021, a cross-sectional study of consecutive adult COVID-19 patients was conducted. Anthropometric data, comorbidities, hospital setting, length of stay, respiratory support, outcome data, and vitamin D status were all evaluated. Results: The length of hospitalization among participants (n = 74; mean age 57.64 ± 17.83 years, 55.4% male) was 18.58 ± 10 days, the majority of the hospital setting was a medical ward (67.6%), and the respiratory support in the form of mechanical ventilation was represented by 12.2%. Hypertension (54.1%), obesity (64.9%), and overweight (64.9%) were the most common cardiometabolic risk factors. In the study group, 44.6% of participants had severe vitamin D deficiency (< 30 nmol/l), while 8.1% had vitamin D insufficiency (50 - 74.9 nmol/l). Furthermore, patients with severe COVID-19 (semi-intensive care unit, intensive care unit) had significantly lower serum 25(OH)D levels (32.9 vs. 20.5 nmol/l; p = 0.007). Participants with severe vitamin D deficiency were older and had more prevalent hypertension, requiring mechanical ventilation; 24.2% experienced a fatal outcome. Conclusions: Severe vitamin D deficiency may contribute significantly to the influence of other cardiometabolic risk factors in COVID-19

Clostridioides Difficile Infection before and during Coronavirus Disease 2019 Pandemic&mdash;Similarities and Differences

The aim of this study was to investigate the differences of Clostridioides difficile infection (CDI) during the COVID-19 pandemic compared to the pre-COVID-19 era. CDI patients treated at the Clinic for Infectious Diseases, Clinical Center of Vojvodina, Serbia during 2017&ndash;2019 (n = 304) were compared with COVID-19/CDI patients treated in period September 2021&ndash;September 2022 (n = 387). Groups were compared by age, gender, comorbidities, previous medications, laboratory findings, and outcome within 30 days. In the CDI/COVID-19 group, we found: greater percentage of males 59.8% vs. 42.6% (p &le; 0.001), older age 72.8 &plusmn; 9.4 vs. 65.6 &plusmn; 11.7 (p &le; 0.001), higher Charlson comorbidity score (CCS) (3.06 &plusmn; 1.54 vs. 2.33 &plusmn; 1.34 (p &le; 0.001), greater percentage of chronic renal failure (33.9% vs. 23.4% (p = 0.003), malignances (24.3% vs. 13.5% (p &le; 0.001), chronic obstructive pulmonary disease (22.7% vs. 15.5% (p = 0.017), higher usage of macrolide (38.5% vs. 8.6% (p &le; 0.001), greater percentage of patients with hypoalbuminemia &le;25 g/L (19.6% vs. 12.2% (p &le; 0.001), lower percentage of patients with elevated creatinine (&ge;200 mmol/L) (31.5% vs. 43.8%) (p = 0.002), and greater percentage of lethal outcome 29.5% vs. 6.6% (p &le; 0.001). In the prediction of lethal outcome multivariate regression analysis extracted as an independent predictor, only higher CRP values in the non-COVID-19 group and in the COVID-19 group: older age (p &le; 0.001), CCS (p = 0.019) and CRP (p = 0.015). COVID-19 changes the disease course of CDI and should be taken into consideration when managing those patients