Uloga mjerenja koncentracije paratireoidnoga hormona u ranom poslijeoperacijskom otkrivanju hipokalcemije nakon operacije štitnjače [The role of parathyroid hormone measurement in early postoperative finding of hypocalcaemia after thyroid gland surgery]

Actual treatment of thyroid diseasse is well established in world community, with a acceptable rate of complications after the surgery. Still, postoperative hypocalcaemia is a major cornstone in one day surgery, and the protocols for the treatment and follow-up are not unique. The role of PTH is very controversal, and in the literature there are many ways of its use. Monitoring for hypocalcemia after thyroidectomy, using only symptoms and serum or ionized calcium levels, can delay the discharge of patients who will remain normocalcaemic and the treatment of hypocalcaemic patients. For these reasons, a prospective study was designed that included 119 patients operated at University Clinical Centre Zagreb at the Department of otorhinolaryngology and Head and Neck surgery from January 2010. til June 2011. with the aim to determine the role of the PTH assay as an early predictor of postoperative disfunction of parathyroids after thyroid surgery, and establish optimal time and number of blood samples for iPTH measurement. According to the results of this study, routine use of this assay should be considered, because it may allow earlier discharge of the normocalcemic patient and earlier identification of patients requiring treatment for postthyroidectomy hypocalcaemi

Acute Coronary Syndrome with ST-segment Elevation in Pregnancy: Anesthetic Management of Delivery

Acute coronary syndrome (ACS) during pregnancy is rare but may be associated with high risk complications. Approximately 150 myocardial infarctions (MI) during pregnancy have been documented in literature worldwide, but we didn’t find one with myocardial aneurysm. We describe 2 patients with acute MI; both with ST segment elevation (STEMI), 1 case complicated with heart failure, formation of a myocardial aneurysm and broad QRS arrhythmia; another with uncomplicated course, and their anesthetic management during delivery. Acute MI is rare in reproductive age usually developing in women with cardiovascular risk factors. There is concern about its rising incidence due to the increase of average maternal age. Our cases show that there might be some undiscovered risk factors for pregnancy related myocardial infarction

Stanje glasa nakon kratkotrajne endotrahealne intubacije u kirurgiji glave i vrata: protokol istraživanja za klinički pokus

Endotracheal intubation is an airway management procedure commonly performed under general anesthesia. It is linked with postoperative voice changes. The incidence and reasons of hoarseness and vocal cord injury are not very well investigated, especially after short-term anesthesia and intubation in head and neck surgery. The aim of the study is to identify the causes of voice changes after short endotracheal anesthesia in head and neck surgery. The study will include patients scheduled for head and neck surgery under general anesthesia with endotracheal intubation up to 3 hours. There will be 3 groups of patients, as follows: thyroid surgery, non-thyroid surgery, and control group undergoing surgery outside head and neck. Videostroboscopy will be recorded before and after surgery. Further diagnostic workup will include voice status; subjective voice self-analysis; perceptive and objective acoustic voice analysis at 4 time points (preoperatively, postoperative day 2, 2 weeks and 1 month after surgery). Endotracheal intubation is a safe method of airway management although it can temporarily alter a patient’s voice quality. It is not known how much of this is the result of anesthesia, general condition of the patient, or surgery. This trial is expected to shed some light on this issue.Endotrahealna intubacija je dio rutinskog anesteziološkog postupka tijekom opće anestezije kojoj su svakodnevno podvrgnuti brojni bolesnici. Povezana je s poslijeoperacijskim promjenama glasa. Incidencija i točni razlozi promuklosti i ozljeda glasnica, pogotovo nakon kratkotrajnih anestezija i intubacija, još uvijek nisu razjašnjeni. Cilj ove studije je pronaći uzroke promjena glasa nakon kratke endotrahealne anestezije u operacijama glave i vrata. Ova prospektivna kohortna studija će uključiti bolesnike predviđene za operacije u području glave i vrata u općoj endotrahealnoj anesteziji do 3 sata. Predviđene su 3 skupine bolesnika: operacija štitnjače, operacija u području glave i vrata te kontrolna skupina s operacijom izvan ove regije. Svim uključenim bolesnicima snimit će se videostroboskopija prije i nakon operacije. Slijedi obrada glasa koja će uključiti glasovni status; subjektivnu samoprocjenu glasa; perceptivnu i objektivnu akustičku analizu glasa u 4 vremenske točke: prije operacije, 2. poslijeoperacijski dan, 14. poslijeoperacijski dan i mjesec nakon operacije. Endotrahealna intubacija je sigurna metoda zbrinjavanja dišnog puta, iako dovodi do kratkotrajne promjene kvalitete glasa bolesnika. Koliko su one posljedica isključivo utjecaja anestezije, općeg stanja bolesnika, a koliko samog operativnog zahvata nije poznato. Rezultati ove studije bi mogli ovo razjasniti

Indikacije za profilaktičku centralnu disekciju vrata kod dobro diferenciranih karcinoma štitnjače

Well-differentiated cancers, both papillary and follicular, account for 90% of all diagnosed thyroid cancers. They have an indolent disease course with a 20-year disease-specific survival over 90%. According to current guidelines, the therapy of choice for well-differentiated thyroid carcinoma is total thyroidectomy or lobectomy. The indication for prophylactic central neck dissection is still a controversial issue and the subject of unfinished and ongoing debate. There is no indication for prophylactic central neck dissection in follicular thyroid carcinomas, which primarily metastasize hematogenously. In small solitary papillary thyroid carcinomas (T1 and T2), prophylactic central neck dissection is not indicated as it does not bring benefits in terms of improved patient survival and at the same time significantly increases the risk of temporary and permanent postoperative complications. Prophylactic central neck dissection is indicated in advanced papillary thyroid cancers (T3 and T4) and all other high-risk well-differentiated thyroid cancer, as well as in the presence of metastatic lymph nodes in the lateral neck.Papilarni i folikularni karcinomi čine 90% svih zloćudnih tumora štitnjače. Dobro diferencirani karcinomi štitnjače imaju indolentan tijek bolesti, s dvadeset godišnjim za bolest specifičnim preživljenjem preko 90%. Totalna tireoidektomija je terapija izbora za većinu bolesnika. Kod bolesnika s karcinomima niskog rizika moguće je učiniti samo lobektomiju zahvaćenog režnja, a da se pritom ne ugrozi ukupno preživljenje bolesnika. Profilaktička disekcija središnjeg dijela vrata predmet je brojnih istraživanja zbog nejasnih kliničkih posljedica njezina izvođenja. Kod folikularnih karcinoma štitnjače koji primarno metastaziraju hematogeno, nema indikacije za profilaktičku disekciju središnjeg vrata. Kod malih solitarnih papilarnih karcinoma štitnjače (T1 i T2) profilaktička disekcija središnjeg vrata nije indicirana, jer ne donosi koristi u smislu poboljšanog preživljavanja pacijenata, a istodobno značajno povećava rizik od privremenih i trajnih postoperativnih komplikacija, poput pareza i paralize povratnog laringealnog živca i hipoparatireoidizma. Ipsilateralna profilaktička disekcija središnjeg vrata indicirana je kod uznapredovalih papilarnih karcinoma štitnjače (T3 i T4) te kod svih ostalih koje karakterizira visok rizik za povrat bolesti ili regionalnu diseminaciju. Metastatski limfni čvorovi na lateralnom vratu, s urednim predoperativnim statusom limfnih čvorova središnje regije vrata, također su indikacija za profilaktičku disekciju središnjeg vrata

Hematom na vratu nakon kateterizacije centralne vene i intubacija na budno kao zbrinjavanje dišnoga puta: prikaz slučaja

Central venous catheterization (CVC) of the internal jugular vein is an invasive procedure commonly performed in anesthesiology practice. Usually it is an uneventful procedure but complications such as bleeding, infection, and potential damage to the surrounding structures can occur. One of the complications is neck hematoma, which can distort airway anatomy and cause upper airway obstruction. We present a patient who underwent endovascular mitral valve repairment procedure under general anesthesia. Accidental puncture of carotid artery occurred while attempting to place the central line. Later, during awakening in the coronary intensive care unit, the patient developed neck hematoma. The diagnosis was confirmed with multi-slice computed tomography (MSCT) and MSCT angiography showed active arterial blood extravasation. Despite it, the patient was extubated. Awake tracheal intubation (ATI) with video laryngoscopy was the technique of choice for reintubation because of the neck swelling and compression onto laryngeal structures. In this case, rushed extubation put the patient at risk. Video laryngoscopy ATI with appropriate preparation and titrated sedation can enable quick and safe rescue airway management in patients with rapidly developing neck hematoma, along with definitive evacuation and treatment.Postavljanje centralnog venskog katetera (CVK) u unutarnju jugularnu venu je invazivan postupak koji se često izvodi u anesteziološkoj praksi. Obično je bez komplikacija, no mogu se dogoditi komplikacije poput krvarenja, infekcije i potencijalnog oštećenja okolnih struktura. Jedna od komplikacija je i hematom vrata koji može narušiti anatomiju dišnih putova i uzrokovati opstrukciju gornjih dišnih putova. Prikazani bolesnik podvrgnut je endovaskularnom popravku mitralnog zaliska u općoj anesteziji. Tijekom pokušaja postavljanja CVK-a došlo je do slučajne punkcije karotidne arterije. Kasnije, tijekom buđenja u koronarnoj jedinici, bolesnik je razvio hematom na vratu. Dijagnoza je potvrđena MSCT-om, a MSCT angiografija pokazala je aktivnu ekstravazaciju krvi. Unatoč tome, bolesnik je ekstubiran. Intubacija na budno (ATI) s video laringoskopom bila je tehnika izbora za reintubaciju zbog otoka vrata i kompresije na dišni put. U prikazanom slučaju ishitrena ekstubacija je bolesnika dovela u opasnost. ATI s video laringoskopom uz odgovarajuću pripremu i titriranu sedaciju može omogućiti brzo i sigurno zbrinjavanje dišnoga puta u bolesnika s brzo razvijajućim hematomom vrata uz evakuaciju i zbrinjavanje uzroka hematoma

Laringealna maska prema endotrahealnoj intubaciji za adenoidektomiju u jednodnevnoj kirurgiji - iskustvo jednog centra

Adenoidectomy with or without tonsillectomy remains one of the most routinely performed surgical procedures in children. The duration of the procedure is usually less than half an hour and is done in a day surgery setting. Airway management for adenoidectomy can be especially challenging as the airway is shared between the surgeon and the anesthesiologist. The gold standard for airway management is an endotracheal tube (ETT), even though there has been an increase in the use of laryngeal mask airway (LMA) over the past decade. This retrospective study investigated patient data collected over a 4-year period (2016 to 2020). Data included 210 cases in a day surgery setting. We analyzed the choice of airway device and use of neuromuscular blockers and analgesics for pain management. The use of LMA was noted in 67.62% while endotracheal intubation was performed in 32.38% of cases. LMA resulted in fewer respiratory complications compared to ETT (p=0.006). The need for neuromuscular blockers was also lower in the LMA group (p=0.01). There was no statistically significant difference in the intraoperative dose of opioid analgesia (p=0.09). Flexible LMA is a satisfactory alternative to endotracheal intubation for outpatient pediatric adenoidectomy.Adenoidektomija, s tonzilektomijom ili bez nje, jedna je od najčešćih kirurških zahvata u djece. Trajanje zahvata obično je kraće od pola sata i izvodi se u uvjetima dnevne kirurgije. Upravljanje dišnim putovima kod adenoidektomije može biti osobito izazovno, jer se dišni put dijeli između kirurga i anesteziologa. Zlatni standard za upravljanje dišnim putovima je endotrahealni tubus, iako se u posljednjem desetljeću češće rabe laringealne maske (LMA). Provedena je retrospektivna studija na 210 bolesnika operiranih tijekom 4-godišnjeg razdoblja (2016. do 2020.) u dnevnoj kirurgiji. Analizirali smo izbor sredstva za osiguranje dišnog puta, primjenu neuromuskularnih blokatora i analgetika za ublažavanje boli. Primjena LMA zabilježena je u 67,62%, dok je endotrahealna intubacija učinjena u 32,38% slučajeva. Nakon LMA zabilježeno je manje respiracijskih komplikacija u usporedbi s ETT (p=0,006). Potreba za neuromuskularnim blokatorima također je bila manja u skupini LMA (p=0,01). Nije pronađena statistički značajna razlika u intraoperativnoj dozi opioidne analgezije (p=0,09). Fleksibilna LMA je zadovoljavajuća alternativa endotrahealnoj intubaciji za ambulantnu pedijatrijsku adenoidektomiju

Anesthesia management of a patient with heart transplant for non-cardiac surgery – case report and literature review

Od prve transplantacije srca 1967. u svijetu se na godinu izvede oko 3500 novih transplantacija srca, uz prosječno posttransplantacijsko preživljenje od 15 godina. Danas je sve češće da skupina pacijenata s transplantiranim srcem bude podvrgnuta nekardijalnim operacijama, što je novi izazov za anesteziološko zbrinjavanje zbog patofizioloških i farmakoloških interakcija s denerviranim presatkom srca, nuspojava imunosupresivne terapije, rizika od infekcije i odbacivanja transplantata. U ovom prikazu pacijentici s transplantiranim srcem potpuno je uklonjena štitnjača (tiroidektomija) zbog papilarnog karcinoma štitnjače. Pacijentica je bila I. kategorije prema klasifikaciji NYHA-e (New York Heart Association) i III. kategorije prema klasifikaciji ASA-e (American Society of Anesthesiologists), uz urednu funkciju alopresatka i stabilan sinusni ritam. Zahvat je izveden u općoj endotrahealnoj anesteziji. Neuromuskularni blok prekinut je sugamadeksom (Bridion®, Merck) i bolesnica je otpuštena kući nakon 3 dana.Since the first human cardiac transplantation in 1967, approximately 3,500 heart transplants are performed every year in the world and post-operation survival period average is 15 years. Due to these facts these patients are now presenting for various non-cardiac procedures. The information regarding the physiological and pharmacological interactions in a denervated allograft heart, the side-effects of immunosuppression, the risk of infection, and the potential for rejection is essential for anesthetic management. This case report reviews the anesthetic management of a heart transplant recipient undergoing a total thyroidectomy. She was NYHA I, ASA grade III with normal alograft function and sinus rhythm. Anesthesia was performed in general endotracheal anesthesia. Neuromuscular block was reversed with sugammadex and she was discharged after three days

Anesteziološki pristup bolesniku s transplantiranim plućima – prikaz bolesnika s pregledom literature

Transplantacija pluća terapija je izbora u bolesnika s posljednjim stadijem plućne insuficijencije uzrokovane najčešće kroničnom bolesti pluća, idiopatskom plućnom fibrozom ili cističnom fibrozom. Stopa preživljenja bolesnika s transplantiranim plućima posljednjih je godina u porastu, kao i potreba za kirurškim intervencijama i anestezijom u tih bolesnika, i to zbog različitih stanja od kojih su najčešća intraabdominalna. Anesteziološki pristup sjedinjuje poznavanje zdravstvenog stanja bolesnika i nuspojava imunosupresivne terapije te fiziologiju i patofiziologiju transplantiranih pluća kako bi odabir anesteziološke tehnike, a time i liječenja bolesnika s transplantiranim plućima imao što povoljniji ishod. Prikazujemo bolesnika koji je nakon obostrane transplantacije pluća podvrgnut općoj anesteziji radi operacije nediferenciranog karcinoma nosa, a kako bismo približili anesteziološke postupke u ove vulnerabilne skupine bolesnika

Hypocalcaemia after Thyroid Surgery for Differentiated Thyroid Carcinoma: Preliminary Study Report

Hypocalcaemia is one of the most common major complications after thyroid surgery with the wide range of incidence from 6.9 to 46%. Thyroidectomy is usually first choice treatment for differentiated thyroid carcinoma (DTC). The study comprised 46 adult patients operated at Zagreb University Hospital Centre. Intraoperative and postoperative ionized calcium and intact parathyroid hormone (iPTH) were studied. The object of this study is to investigate risk factors, incidence of hypocalcaemia after surgical treatment of differentiated thyroid carcinoma, and the role of iPTH in comparison to ionized calcium as a predictor for hypocalcaemia

Anesthesia of a child with open Botalli’s duct – a case report

Osmogodišnji dječak naručen je na elektivnu tonzilektomiju zbog ponavljanih upala srednjeg uha uzrokovanih hipertrofijom adenoida. Pacijent je imao otvoreni, tj. perzistentni arterijski duktus (engl. Persistent ductus arteriosus – PDA), čestu prirođenu srčanu grešku s očuvanom komunikacijom između aorte i plućne arterije. Kod pacijenta je postojao samo hemodinamski neznatan lijevo-desni pretok. Trenutačne smjernice za anesteziju pacijenata s lijevo-desnim pretokom uključuju: 1. održavanje ili smanjenje sustavnoga vaskularnog otpora (SVR) kao hemodinamski cilj; 2. izbjegavanje smanjenja plućnoga vaskularnog otpora (PVR); 3.izbjegavanje hiperoksije i hipokarbije. Predoperacijska obrada uključivala je suradnju s pedijatrijskim kardiologom koji je napravio procjenu pacijentova srčanog statusa, uključujući ultrazvuk srca i elektrokardiogram (EKG). Tijek anestezije protekao je bez neželjenih događaja. Nakon reverzije neuromuskularne blokade i ekstubacije pacijent je budan, hemodinamski stabilan i zadovoljavajućega respiratornog stanja prebačen u sobu za oporavak poslije anestezije. Preoksigenacija 100%-tnim kisikom prijeporna je u ovakvih pacijenata. Detaljna predoperacijska procjena srčanog statusa i izbjegavanje povećanja protoka kroz otvorenu komunikaciju ključni su za dobar ishod u pacijenata s PDA-om.The 8-year-old boy was scheduled for an elective tonsillectomy because of a recurring middle ear infection, caused by adenoid hypertrophy. The patient had a patent ductus arteriosus (PDA), a common congenital heart defect with a persistent communication between the aorta and the pulmonary artery. In this patient, there was only a haemodynamically insignificant left-to-right shunt. Current guidelines for anaesthetic management of patients with left-to-right shunt include: 1. Maintenance or decrease of systemic vascular resistance (SVR) as a haemodynamic goal; 2. Avoiding decreases in pulmonary vascular resistance (PVR); 3. Avoiding hyperoxia and hypocarbia. The preoperative assessment included collaboration with paediatric cardiologist who reevaluated the patient’s cardiac status, including a heart ultrasound and an ECG cardiography. The course of anaesthesia was uneventful. After neuromuscular blockade reversion and extubation, the patient was transferred to the post-anesthesia care unit (PACU) awake, haemodynamically stable and with satisfactory respiratory status. The preoxygenation with 100% oxygen is a source of controversy. In a patient with PDA, a thorough preoperative evaluation of cardiac status and avoidance of worsening left-to-right shunt are essential for good outcome