Bolesničko pomazanje u jedinici intenzivne medicine - posljednji pozdrav ili poziv u pomoć

The right of a conscious and competent patient to self-determination and the ability to make decisions about their own treatment affects the treatment outcome decisively. The patient’s acceptance or rejection of the treatment options the doctor offers directs active medical interventions towards one of the goals: curing the disease or reducing suffering. In accordance with the provisions of the Health Care Act, every person has the right to practice religious rites during their stay in a hospital in the area provided for that purpose. During the COVID-19 pandemic, the functioning of the health system was changed. The need for isolation has led to a ban on visits and limited patients’ communication with their families and loved ones, which was only possible using cell phones. Priests were allowed access, but with all infection prevention measures regarding medical staff. In that environment, the Anointing of the Sick remained the only active intervention that the ill person’s family was able to do for their loved ones. For the family of the critically ill, the entry of a priest into a “forbidden space” is a spiritual act in which the priest can communicate with the sick in the role of an emissary of the family. He can also perform instrumental interventions by the act of anointing with blessed oil, with a desire for healing. The aim of this text is to outline some of the aspects of isolating critically ill patients from their families and the role of the Anointing of the Sick in this situation.Pravo svjesnog i kompetentnog pacijenta na samoodređenje i mogućnost donošenja odluka o vlastitom liječenju značajna je odrednica liječenja. Pacijentovo prihvaćanje ili odbijanje ponuđenih mogućnosti liječenja od strane liječnička usmjerava aktivne medicinske intervencije ka jednom od ciljeva: izlječenje bolesti ili smanjenje patnje. Svaka osoba u skladu s odredbama Zakona o zdravstvenoj zaštiti ima pravo obavljanje vjerskih obreda za vrijeme boravka u zdravstvenoj ustanovi u za to predviđenome prostoru. Tijekom pandemije COVID-19 dogodile su se brojne promjene u funkcioniranju zdravstvenog sustava. Potreba za izolacijom dovela je do zabrane posjeta i ograničene komunikacije pacijenata s obitelji i bližnjima koja je moguća uporabom mobitela. Pristup svećenika uz sve mjere zaštite od infekcije koje se odnose na osoblje medicinskih struka, bio je dozvoljen. Bolesničko pomazanje u tom je okruženju ostalo jedina intervencija i aktivni čin koji je obitelj oboljelog mogla napraviti za svojeg bližnjeg. Ulazak svećenika u „zabranjeni prostor“ za obitelj teško bolesnog predstavlja spiritualni čin u kojem svećenik može komunicirati s bolesnikom, u ulozi poslanika obitelji. On također može obaviti instrumentalnu intervencije činom pomazanja blagoslovljenim uljem, sa željom ozdravljenja. Cilj je ovog teksta iznijeti neke od aspekata izolacije kritično oboljelih pacijenata od obitelji i ulogu bolesničkog pomazanja u ovoj situaciji

Intact Radial and Median Nerve after Open Third Degree Distal Fracture of the Humerus

A 54 year old man sustained a third degree open fracture at the distal part of the right humerus with massive soft tissue defect involving most of the upper arm. The radial and median nerves were completely bared and exposed by 6 cm for radial and 3 cm for median nerve. The nerves were in continuity, but there was complete rupture of surrounding muscles: biceps, triceps and brachialis. The fracture was stabilized by external fixation method – reinforced by wires. Preoperative and postoperative sensorimotor status of the right hand was good. One year later sensory and motoric status of right hand showed no deficiencies, but flexion and extension in elbow were limited to 100 and 180 degrees respectively. Pronosupination was restricted. This case report is consistent with results of biomechanical studies in vitro confirming high tolerance of radial and median nerve to stretching injury

Bolesničko pomazanje u jedinici intenzivne medicine - posljednji pozdrav ili poziv u pomoć

The right of a conscious and competent patient to self-determination and the ability to make decisions about their own treatment affects the treatment outcome decisively. The patient’s acceptance or rejection of the treatment options the doctor offers directs active medical interventions towards one of the goals: curing the disease or reducing suffering. In accordance with the provisions of the Health Care Act, every person has the right to practice religious rites during their stay in a hospital in the area provided for that purpose. During the COVID-19 pandemic, the functioning of the health system was changed. The need for isolation has led to a ban on visits and limited patients’ communication with their families and loved ones, which was only possible using cell phones. Priests were allowed access, but with all infection prevention measures regarding medical staff. In that environment, the Anointing of the Sick remained the only active intervention that the ill person’s family was able to do for their loved ones. For the family of the critically ill, the entry of a priest into a “forbidden space” is a spiritual act in which the priest can communicate with the sick in the role of an emissary of the family. He can also perform instrumental interventions by the act of anointing with blessed oil, with a desire for healing. The aim of this text is to outline some of the aspects of isolating critically ill patients from their families and the role of the Anointing of the Sick in this situation.Pravo svjesnog i kompetentnog pacijenta na samoodređenje i mogućnost donošenja odluka o vlastitom liječenju značajna je odrednica liječenja. Pacijentovo prihvaćanje ili odbijanje ponuđenih mogućnosti liječenja od strane liječnička usmjerava aktivne medicinske intervencije ka jednom od ciljeva: izlječenje bolesti ili smanjenje patnje. Svaka osoba u skladu s odredbama Zakona o zdravstvenoj zaštiti ima pravo obavljanje vjerskih obreda za vrijeme boravka u zdravstvenoj ustanovi u za to predviđenome prostoru. Tijekom pandemije COVID-19 dogodile su se brojne promjene u funkcioniranju zdravstvenog sustava. Potreba za izolacijom dovela je do zabrane posjeta i ograničene komunikacije pacijenata s obitelji i bližnjima koja je moguća uporabom mobitela. Pristup svećenika uz sve mjere zaštite od infekcije koje se odnose na osoblje medicinskih struka, bio je dozvoljen. Bolesničko pomazanje u tom je okruženju ostalo jedina intervencija i aktivni čin koji je obitelj oboljelog mogla napraviti za svojeg bližnjeg. Ulazak svećenika u „zabranjeni prostor“ za obitelj teško bolesnog predstavlja spiritualni čin u kojem svećenik može komunicirati s bolesnikom, u ulozi poslanika obitelji. On također može obaviti instrumentalnu intervencije činom pomazanja blagoslovljenim uljem, sa željom ozdravljenja. Cilj je ovog teksta iznijeti neke od aspekata izolacije kritično oboljelih pacijenata od obitelji i ulogu bolesničkog pomazanja u ovoj situaciji

ETHICAL ASPECTS OF ANENCEPHALIC INFANTS AS ORGAN DONORS

Sve su uspješniji kirurški postupci transplantiranja organa, kao i skrbi primatelja i transplantacijske imunologije kada su u pitanju dojenčad i dijeca primatelji. Uspjeh transplantacijske medicine, općenito, neovisno o dobi, ograničen je brojem kvalitetnih doniranih organa. Dijete primalac ima čimbenik fi zičkog ograničenja određen prikladnom veličinom organa. S toga se vrlo rano još 80-tih godina prošlog stoljeća pokrenulo razmatranje o djeci donorima s proširenim kriterijima smrti iz čega bi slijedilo donorstvo organa dojenčadi s potvrđenom kongenitalnom abnormalnosti anencefalije. Mnoge su etičke, zakonske i medicinske dvojbe u odluci i raspravi može li se i kada pristupiti doniranju organa i tkiva od djeteta s anencefalijom.Organ transplantation and other related procedures in newborns and children are becoming ever more advanced and successful. Generally, success of transplantation medicine is limited by the availability of donated organs, irrespective of age. Appropriately sized donated organs pose physical limitation for children recipients. Therefore, since the early 1980s, consideration has been given to infant donors with modifi ed death criteria that would result in organ donation from newborns with confi rmed congenital anencephaly. Numerous ethical, regulatory and medical ambiguities surround discussion and decision making process if and when it is possible to donate organs of anencephalic infants

ETHICAL ASPECTS OF ANENCEPHALIC INFANTS AS ORGAN DONORS

Sve su uspješniji kirurški postupci transplantiranja organa, kao i skrbi primatelja i transplantacijske imunologije kada su u pitanju dojenčad i dijeca primatelji. Uspjeh transplantacijske medicine, općenito, neovisno o dobi, ograničen je brojem kvalitetnih doniranih organa. Dijete primalac ima čimbenik fi zičkog ograničenja određen prikladnom veličinom organa. S toga se vrlo rano još 80-tih godina prošlog stoljeća pokrenulo razmatranje o djeci donorima s proširenim kriterijima smrti iz čega bi slijedilo donorstvo organa dojenčadi s potvrđenom kongenitalnom abnormalnosti anencefalije. Mnoge su etičke, zakonske i medicinske dvojbe u odluci i raspravi može li se i kada pristupiti doniranju organa i tkiva od djeteta s anencefalijom.Organ transplantation and other related procedures in newborns and children are becoming ever more advanced and successful. Generally, success of transplantation medicine is limited by the availability of donated organs, irrespective of age. Appropriately sized donated organs pose physical limitation for children recipients. Therefore, since the early 1980s, consideration has been given to infant donors with modifi ed death criteria that would result in organ donation from newborns with confi rmed congenital anencephaly. Numerous ethical, regulatory and medical ambiguities surround discussion and decision making process if and when it is possible to donate organs of anencephalic infants

Traheobronhalna morfometrija korelira s demografskim obilježjima i infekcijama u kritično oboljelih pacijenata

Tracheal measurements in the intensive care unit (ICU) are important for the choice of endotracheal tube and may correlate with patient demographic characteristics and infections. The study included 42 surgical patients, age 60 [48-71] years, who underwent diagnostic chest computed tomography (CT) scans during treatment in the ICU, Osijek University Hospital, in 2019 and 2020. CT scans were analyzed using AW Server 3.2. Measurement analysis showed that the diameters of the tracheobronchial tree, the length of the trachea and left main bronchus were significantly larger in men compared to women (p<0.05 all). The smallest tracheal upper diameter was 15.25 [IQR 11.8-18.8] mm vs. 17.95 [13.55-20.05] mm in septic and nonseptic patients, respectively (p=0.028). A total of 26 patients who underwent CT scans developed nosocomial pneumonia. It was right-sided in 15, left-sided in 6 and bilateral in 5 patients, and correlated significantly with the left main bronchus length (ρ=0.515, p=0.007). No correlation was observed between tracheobronchial measurements and length of ICU treatment, number of hours spent on mechanical ventilation, or survival. A larger study could provide better data on the importance of tracheobronchial tree measurements in ICU patients.Izmjere traheje u jedinici intenzivnog liječenja (JIL) važne su zbog odabira veličine tubusa te mogu korelirati s demografskim obilježjima bolesnika i infekcijama. U ovoj studiji su analizirana 42 kirurška bolesnika u dobi od 60 [48-71] godina kojima je učinjena dijagnostička kompjutorizirana tomografija (CT) prsnog koša za vrijeme liječenja u JIL-u Kliničkog bolničkog centra Osijek tijekom 2019. i 2020. godine. Snimci CT-a su analizirani programom AW Server 3.2. Analiza izmjera pokazala je da su promjeri traheobronhalnog stabla, duljina dušnika i lijevog glavnog bronha značajno veći kod muškaraca nego kod žena (p<0,05 za sve). Najuži gornji promjer dušnika bio je 15,25 [IQR 11,8-18,8] naspram 17,95 [13,55-20,05] mm u septičkih i neseptičkih bolesnika (p=0,028). Kod ukupno 26 bolesnika koji su podvrgnuti CT-u tijekom liječenja u JIL-u dijagnosticirana je pneumonija. Bila je desnostrana u 15, lijevostrana u 6, a obostrana u 5 bolesnika i značajno je korelirala s duljinom lijevog glavnog bronha (ρ=0,515, p=0,007). Nije uočena korelacija između traheobronhalnih mjerenja i duljine liječenja u JIL-u, duljine mehaničke ventilacije ili preživljenja. Veća studija bi mogla pružiti bolje podatke o značenju dimenzija traheobronhalnog stabla kod kritično oboljelih pacijenata

A wound infiltration as a method of postoperative analgesia

A wound infiltration is a method of postoperative analgesia efficient in the various surgical subdisciplines. This technique resulted from the observation that patients whose surgical procedures were performed under regional anaesthesia techniques have reduced postoperative analgesic consumption. Owing to the advances in the drug discovery and to the introduction of local anaesthetics with prolonged effects, this technique has less adverse reactions and considerable analgesic effects. New local anaesthetics with long duration of action and low toxicity like levobupivacaine and ropivacaine are currently available at the market. Such drugs with lower potential for systemic toxicity provided additional safety dimension to local infiltration techniques. A variety of methods were developed to achieve painless recovery period, better patient comfort and to improve patient outcome. Probably the most common technique is a field block at the end of the surgery that can be performed both during regional anaesthesia techniques and in the general anaesthesia. The use of wound infiltration techniques was facilitated by important technical improvements in the multilumen catheters and by construction of special drug delivery devices. Numerous disposable elastomeric devices and patient controlled pumps are suitable for prolonged periods of analgesia in the clinical and outpatient setting. Although it can be used alone for less painful procedures, infiltration analgesia is now important part of multimodal pain treatment. This complex approach to the postoperative pain treatment is characterized by the use of different analgesic drugs and techniques, like wound infiltration and intravenous opioid or nonsteroidal anti-inflammatory drugs. Multimodal postoperative pain treatment is acceptable after painful procedures i.e. hip and knee replacement, where it improves pain control and patient outcome

SUGAMMADEX, A NEW DRUG FOR REVERSION OF MUSCLE RELAXANTS

Sugamadeks je novi lijek za reverziju neuromuskularnog bloka. Po kemijskoj građi on je alfa-ciklodekstrin s lipofilnom unutrašnjom stranom molekule koja omogućuje stvaranje stabilnih kompleksa, tzv. enkapsulaciju molekula mišićnih relaksatora, napose rokuronija. Fizička enkapsulacija novi je mehanizam eliminacije relaksatora s mjesta njegova učinka. Ona omogućuje brzu i potpunu reverziju dubokog i plitkog neuromuskularnog bloka ovisnu o primijenjenoj dozi. Sugamadeks nema neželjenih kolinergičkih muskarinskih nuspojava koje se opažaju nakon primjene inhibitora kolinesteraze neostigmina i edrofonija kao što su bradikardija, hipersalivacija i abdominalne boli. Nakon primjene prilagođene doze sugamadeksa učinak rokuronija može biti kratak kao i učinak sukcinilkolina. Ovo je osobito važno u situacijama kada se bolesnik ne može intubirati niti ventilirati ili kada je kirurški zahvat nepredviđeno brzo završen. Kliničke studije na većem broju bolesnika pokazat će omjer koristi i rizika njegove primjene u skupinama osjetljivih bolesnika, osobito može li sugamadeks smanjiti učestalost poslijeoperacijskih respiracijskih komplikacija.Sugammadex is a new pharmacological agent for neuromuscular block reversion. It is a cyclic oligosaccharide, a gamma cyclodextrin with lipophylic inner coat that enables forming of stable complexes with steroidal neuromuscular blocking drugs, especially with rocuronium. A physical encapsulation of the relaxants is a novel elimination pathway and it produces fast and complete reversion of both deep and shallow neuromuscular block. Consequently, sugammadex has no unwanted cholinergic muscarinic effects observed with cholinesterase inhibitors such as bradycardia, hypersalivation, and increased gastrointestinal motility. Since the effects of sugammadex are dose dependent it can very rapidly reverse the effects of rocuronium. After the adjusted dose of sugammadex was given, the duration of action of rocuronium can be made as short as that of succinylcholine. This characteristic is especially important in the ’can’t intubate, can’t ventilate’ situation and after surgical procedure was unexpectedly finished. Clinical studies involving more patients are needed to show the real risk-benefit profile and safety in the special patients’ population

PLACEBO IN THE PAIN TREATMENT

Uporaba farmakološki neaktivnih tvari ili postupaka poznatih kao ’placebo’ uvriježena je u medicinskim krugovima pri ispitivanju lijekova. Njihova primjena ima veliku važnost u kontroliranim kliničkim studijama liječenja boli i u istraživanjima mehanizama prijenosa bolnih podražaja. Novije studije pokazale su da je učinak placeba mjerljiv, praćen promjenama moždane aktivnosti i odgovarajućega subjektivnog doživljaja intenziteta boli. U ovom članku opisane su promjene koje se događaju kod placebne analgezije, intenzitet smanjenja boli u usporedbi s aktivnim lijekovima te osnovni problemi pri primjeni placeba u kliničkoj praksi i istraživanjima.Use of medical preparations having no specific pharmacological activity or dummy procedures administered to patients is known as placebo. Such maneuvers are important in the pain treatment and clinical studies investigating pain mechanisms. Several recent studies have shown that placebo treatment produces measurable psychophysiological effects, characterized by changes in specific brain functions and decreased subjective pain perception. This article reviews changes observed in placebo analgesia, its intensity as compared to active compounds, and principal problems observed during the placebo treatment and in clinical trials