SPECIFIC ASPECTS OF ANESTHESIA IN PROCTOLOGY

Proctology, as a domain of abdominal surgery, deals with the treatment of diseases affecting the end part of the large bowel, it’s terminal 20 cm, to which anus anatomically belongs as well. In view of the physiological role of this part of the digestive tract (stool control), all the diseases and disorders in the region cause patient discomfort and produce significant problems in everyday life. On account of that, diagnostic management should be performed promptly in order that effective treatments could be introduced as soon as possible. The most commonly used techniques of anesthesia in proctology are local anesthesia, independent or in combination with intravenous analgosedation, regional anesthesia (spinal and epidural), and general anesthesia. Local anesthesia combined with analgosedation has been the preferred approach in recent studies, since it is able to provide adequate settings for the planned surgery, patient comfort and minimization of side effects. An adequate anesthesia technique reduces metabolic response to surgical stress and length of hospitalization, which markedly affects cost-effectiveness of the treatment

Utjecaj intraabdominalnog tlaka na osnovne vitalne funkcije i ishod liječenja

The purpose of the study was to point to the importance of measuring intra-abdominal pressure (IAP) and of early recognition of the consequences of increased IAP on basic vital functions. Measurement of IAP via urinary bladder was conducted every 12 hours in 70 surgical patients with acute abdominal syndromes not previously operated on. Based on the measured IAP values, all patients were divided into groups of patients with normal IAP values (n=20) and patients with increased IAP values (n=50) . Vital functions and basic laboratory analysis were monitored and the values obtained were compared with IAP in both patient groups. A statistically significant difference was found in body weight, body mass index, urine output, creatinine, urea, heart rate, partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) between patients with normal and increased IAP values. The increase in IAP values was found to be associated with an increase in PaCO2, respiratory rate, peak inspiratory pressure, central venous pressure, heart rate, Acute Physiology, Age and Chronic Health Evaluation II score, mortality rate, creatinine and urea values, and number of days of treatment in the intensive care unit. At the same time, the values of PaO2, blood oxygen saturation, diuresis and abdominal perfusion pressure were declining. IAP measurement is an old, cost-effective, reliable technique that is easy to perform and should be applied in all high risk patients.Cilj studije bio je ukazati na značenje mjerenja intraabdominalnog tlaka (intra-abdominal pressure, IAP) i ranog prepoznavanja promjena osnovnih vitalnih funkcija, koje su posljedica povećanja IAP. Mjerenje IAP je provedeno kroz mokraćni mjehur svakih 12 sati kod 70 bolesnika s akutnim abdominalnim sindromom koji nisu prethodno operirani. Na osnovi izmjerenih vrijednosti IAP bolesnici su podijeljeni u skupinu s normalnim vrijednostima IAP (n=20) i skupinu s povećanim vrijednostima (n=50). Praćenjem osnovnih vitalnih funkcija i laboratorijskih analiza dobivene vrijednosti uspoređivane su u odnosu na IAP u objema skupinama bolesnika. Statistički značajna razlika između bolesnika s normalnim i onih s povišenim IAP utvrđena je za tjelesnu težinu, indeks tjelesne mase, diurezu, vrijednosti kreatinina, ureju, srčanu frekvenciju, parcijalni tlak kisika (PaO2) i parcijalni tlak ugljičnog dioksida (PaCO2). Također je zapaženo da su s porastom IAP rasle i vrijednosti PaCO2, broja respiracija, vršnog inspiracijskog tlaka, centralnog venskog tlaka, srčane frekvencije, akutna fi zio loška, starosna i kronična evaluacija zdravlja II (Acute Physiology, Age and Chronic Health Evaluation, APACHE), stopa smrtnosti, vrijednosti ureje i kreatinina te broj dana liječenja u jedinici intenzivnog liječenja, dok su vrijednosti PaO2, zasićenje hemoglobina kisikom, diureza i abdominalni perfuzijski tlak bili u opadanju. Mjerenje intraabdominalnog tlaka je stara, jeftina, pouzdana metoda, jednostavna za izvođenje kod svih visoko rizičnih bolesnika

Upravljanje antibioticima vođeno prokalcitoninom: konsenzus eksperata iz balkanskih zemalja

Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program.Sepsa kao posljedica infekcije jedan je od čestih uzroka smrti među kritično oboljelim pacijentima. Najčešća mjesta infekcije su donji respiracijski putovi, abdomen, mokraćni sustav i infekcije krvi povezane s centralnim vesnkim kateterima. Rana empirijska upotreba antibiotika širokog spektra kod onih s teškom sepsom/septičnim šokom radi smanjivanja smrtnosti može voditi prekomjernoj upotrebi antibiotika, bakterijskoj rezistenciji i povećanju troškova. Među mnogobrojnim serumskim biološkim biljezima prokalcitonin se pokazao kao jedan od najpouzdanijih u dijagnosticiranju sepse. Jedan od bitnih načina za smanjenje bakterijske rezistencije predstavlja uvođenje protokola o upotrebi antibiotika, naročito među kritično oboljelima u jedinicama intezivnog liječenja gdje su prisutni multirezistentni patogeni. Prokalcitoninom vođeni protokoli za upotrebu antibiotika prvo su uvedeni u Zapadnoj Europi i Azijsko-pacifičkim zemljama, kao i u Americi. S obzirom na to da se ovakav program pokazao učinkovitim u pogledu potrošnje antibiotika, a ujedno i u poboljšanju ishoda liječenja, grupa eksperata s Balkana odlučila je napraviti svoje vlastite preporuke. Tijekom izrade ovog protokola za uvođenje i dužinu trajanja antibiotskog liječenja autori su se uglavnom usredotočili na pretragu literature koja se tiče donjeg respiracijskog sustava i sepse. Protokol uključuje težinu bolesti, kliničku procjenu i razine prokalcitonina. Razvijanje konsenzusa o kliničkom algoritmu od strane eminentnih stručnjaka iz različitih područja medicine trebalo bi omogućiti kliničarima da prokalcitonin koriste pri donošenju odluke o započinjanju i ranijem prestanku terapije antibioticima. Neophodno je da prokalcitoninom vođen algoritam postane sastavni dio institucionalnog protokola o upotrebi antibiotika

PERIPARTUM CARDIOMYOPATHY IN INTENSIVE CARE UNIT:AN UPDATE

Peripartum cardiomyopathy (PPCM) is a systolic heart failure that occurs during the last month of pregnancy or within five months after delivery. It is uncommon disease of unknown ethiopatogenesis and very high rate of maternal mortality. Because of similarity between symptoms of PPCM and physiological discomforts during pregnancy, the early diagnosis of PPCM presents a major challenge. Since hemodynamic changes during PPCM can vitally jeopardise the mother and the fetus, patients with severe forms of PPCM require a multidisciplinary approach in intensive care units. This review summarize the current state of knowledge about the diagnosis, monitoring, and the treatment of PPCM. Having reviewed the recent researches it gives insight into the new treatment strategies of this rare disease

Safe extubation and reintubation in operatory room and ICU patients

Each intubation should result in an extubation at end of procedure, and each extubation, theoretically, could represent a potential reintubation due to extubation manoeuvre failure. There are many and different reasons for extubation to fail, starting from mechanical iatrogenic lesions due to difficult intubation up to patient's inhability to sustain spontaneous breathing and unassisted ventilation, going through extubation associated respiratory and cardiovascular complications, local mechanic or inflammatory factors, surgical techniques and accidental events. Recent literature has clearly shown that if critical events associated with difficult intubation have lower incidence thanks to guidelines diffusion and implementation, extubation related accidents did not change incidence and consequences in last couple of decades. This observation has led to developement of dedicated extubation guidelines and to attention from Scientific Community to promote culture of safety and anticipation, with predicted difficult extubation concept and protected extubation strategies, by using pharmacological and technical approach. Aim of this paper is to review data for extubation related accidents, to provide overview with existing guidelines and description of approaches to predict difficult extubation, techniques to provide best extubation strategies including pharmacologic, non pharmacologic and instrumental techniques

ADMINISTRATION OF EPIDURAL ANESTHESIA IN OPERATIONS OF INGUINAL HERNIAS – COMPARISON OF DIFFERENT ANESTHETICS’ CONCENTRATIONS

In operations of inguinal hernias, different techniques of anesthesia administration are used, but in the last years, there has been a great interest in the local-regional anesthesia, primarily in epidural. The aim of the study was to ascertain the efficiency and safety of administration of minor anesthetics’ concentrations in epidural anesthesia in operations of inguinal hernias. The assessment of patient’s stability by monitoring of vital functions included: noninvasive measuring of blood pressure, pulse, ECG, respiratory frequency and diuresis. Also, in order to assess the effect of anesthetic action of lidocaine, we followed up the onset and ending of sensory blockade, motor blockade, pain intensity during surgical intervention with the use of VAS.There was no statistically significant difference regarding the onset and ending of sensory blockade between greater (20 ml 2% lidocaine) and minor concentrations (20 ml 1,5% lidocaine) administered epidurally. However, all the examinees to whom 2% lidocaine was administered, had the motor blockade which occurred after 14,37 ±1,04 min, and was in duration of 110,45±13,20 min. Only 20% of patients to whom 1,5% lidocaine was administered had the motor blockade, in whom it occurred after 11,16± 2,02 min, and was in duration of 100,30 ±8,40 min.Systolic pressure significantly decreased between the fifth and tenth minute after 20 ml of 2% lidocaine administration compared to the group to whom 20 ml of 1,5% lidocaine was administered, with statistical significance (p<0,01). Also, we registered decrease in pulse frequency in both groups, as well as the fact that the patients to whom 20 ml of 2% lidocaine was administered, had to stay in bed longer in the postoperative period. Comparing other hemodynamic parameters, there was no statistically significant difference. We can conclude that minor concentrations of anesthetics can be efficient and safe to administer in epidural anesthesia, because they achieve adequate analgesia for a surgical intervention. The possibility of toxic symptoms’ occurrence is smaller, when compared to greater doses and concentrations of anesthetics

Enhanced Recovery after Vascular Surgery

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients

Quality of Life Indicators in Patients Operated on for Breast Cancer in Relation to the Type of Surgery—A Retrospective Cohort Study of Women in Serbia

Background and objectives: Quality of life (QoL) after breast cancer surgery is an important public health issue. The aim of this study was to determine the relationship between the levels of perceived quality of life in patients operated on for breast cancer in relation to the type of surgery, using the standardized questionnaires. Materials and Methods: We assessed 425 women after surgery for breast cancer. The assessment included the application of the WHOQOL-bref (The World Health Organization Quality of Life-Bref), and FACT-B (Functional Assessment of Cancer Therapy-Breast) questionnaires. The statistical analysis of the data included multiple linear regression and correlation tests. Results: Multiple linear regression analysis found that education, existence of comorbidities, time elapsed since surgery, and type of surgery were significant predictors of overall quality of life. Women&rsquo;s overall quality of life and general health has increased by 0.16 times for each subsequent year of surgery, and by 0.34 times for each subsequent higher education level. Breast-conserving surgery or mastectomy with breast reconstruction were statistically significant (&beta; = 0.18) compared to total mastectomy. Conclusions: There is a significant difference in the quality of life perceived by patients in whom the breast has been preserved or reconstructed in relation to patients in whom total mastectomy has been performed