Anesteziološki postupak kod bolesnika s kompresijom središnjega dišnog puta zbog mase u stražnjem medijastinumu

Patients with mediastinal masses present unique challenge to anesthesiologists. Patients with anterior mediastinal masses have well documented cases of respiratory or cardiovascular collapse during anesthesia and in postoperative period. Masses in the posterior mediastinum have been traditionally regarded to carry a significantly lower risk of anesthesia related complications but cases of near fatal cardiorespiratory complications have been reported. We describe anesthetic management of a patient with posterior mediastinal mass compressing the trachea and the left main bronchus presented for left thoracotomy and tumor excision. The patient experienced pain and cough, and exhibited positional dyspnea. Airway was successfully secured with awake nasotracheal intubation and placement of single lumen endobronchial tube.Bolesnici s masama u medijastinumu predstavljaju jedinstven izazov za anesteziologe. U literaturi se uglavnom govori o anesteziološkim postupcima kod bolesnika s masama u prednjem medijastinumu za koje postoje brojni dobro dokumentirani slučajevi respiracijskog i kardiovaskularnog kolapsa tijekom anestezije i u poslijeoperacijskom razdoblju. Smatra se da mase u stražnjem medijastinumu imaju značajno manji rizik vezan za anesteziju, ali su i kod ovih bolesnika opisani slučajevi teških perioperacijskih kardiorespiracijskih komplikacija. Prikazan je anesteziološki postupak kod bolesnice s tumorom u stražnjem medijastinumu koji je uzrokovao kompresiju traheje i lijevog glavnog bronha, predviđene za torakotomiju i eksciziju tumora. Bolesnica je imala simptome kašlja, bolova i dispneje u ležećem položaju. Dišni put je uspješno osiguran nazotrahealnom intubacijom budne bolesnice i postavljanjem jednoluminalnog endobronhalnog tubusa

Primjena epiduralne analgezije kod višestruko ozlijeđenih bolesnika s teškom traumom prsnog koša: dva prikaza slučaja i pregled literature

Multiply injured patients with severe chest trauma have different combinations of associated extra thoracic injuries making their treatment complex. Severe pain is a prominent symptom in a vast majority of severe chest injuries and causes deterioration of respiratory function. Epidural analgesia provides efficient pain relief but its use in this group of patients is burdened with complications, contraindications and technical difficulties. We present two cases in which epidural analgesia was successfully used in polytrauma patients with severe chest injuries and hypoxemic respiratory failure, and discuss advantages, possible pitfalls and complications.Bolesnici s teškom ozljedom prsnog koša često imaju različite pridružene ozljede drugih organskih sustava što čini njihovo liječenje vrlo kompleksnim. Bol je prominentan simptom teških ozljeda prsnog koša i neliječena doprinosi pogoršanju respiratornog statusa. Epiduralna analgezija je učinkovita metoda liječenja boli, ali je njena upotreba u ovoj skupini bolesnika često ograničena specifičnim kontraindikacijama, mogućim komplikacijama i tehničkim poteškoćama. Prikazujemo dva slučaja u kojima je uspješno primjenjena epiduralna analgezija kod politraumatiziranih bolesnika s teškom ozljedom prsnog koša i hipoksemičnim respiratornim zatajenjem

Nausea and vomiting - the "big little problem" during recovery after anesthesia

Poslijeoperativna mučnina i povraćanje česte su i vrlo neugodne nuspojave u bolesnika nakon primjene anestezije. Unatoč primjeni modernih anestetika i minimalno invazivnih kirurških tehnika, učestalost ove nuspojave još uvijek je velika, te iznosi i do 30% kada se koristi antiemetska profilaksa. Ukoliko nema antiemetske zaštite može biti čak i do 80%. Etiološki, poslijeoperativna mučnina i povraćanje uzrokovane su brojnim čimbenicima koji mogu proizlaziti iz određenih karakteristika i sklonosti pacijenta, anestezioloških lijekova, te vrste operacije i kirurške tehnike. Procjena čimbenika povećanog rizika za nastanak poslijeoperativne mučnine i povraćanja pomaže anesteziolozima u odabiru najprikladnije antiemetske zaštite. Terapijski postupci kod poslijeoperativne mučnine i povraćanja obuhvaćaju procjenu bolesnikovog rizika za njihov nastanak, strategiju smanjenja osnovnog rizika, primjenu antiemetske zaštite kod bolesnika s umjerenim i visokim rizikom, te tretiranje mučnine i povraćanja nakon neuspješne antiemetske zaštite. Osnovni rizik svakog pojedinog bolesnika potrebno je objektivno procijeniti pomoću validiranog bodovnog zbroja koji sadrži nekoliko prediktora. Predviđanje nastanka poslijeoperativne mučnine i povraćanja pomoću prediktivnih modela ima umjerenu pouzdanost. Danas poznati modeli predviđanja za nastanak poslijeoperativne mučnine i povraćanja imaju praktičnu vrijednost za stupnjevanje rizika, no osuvremenjen individualni pristup pojedinom bolesniku potreban je za utvrđivanje klinički važne poslijeoperativne mučnine i povraćanja. Kliničko iskustvo anesteziologa i poznavanje pouzdanosti i sigurnosti farmakoloških i nefarmakoloških antiemetskih metoda može poboljšati zadovoljstvo bolesnika, ujedno smanjujući poslijeoperativni pobol i troškove liječenja. Nova istraživanja o ulozi gena u individualnom odgovoru bolesnika na antiemetske lijekove može pomoći kliničarima u oblikovanju terapije poslijeoperativne mučnine i povraćanja prilagođene svakom pojedinom kirurškom bolesniku.Postoperative nausea and vomiting (PONV) are the most common and very unpleasant side effects after general anesthesia. Despite modern anesthetics and non-invasive surgical techniques, the overall incidence still remains high. It is about 30% even with PONV prophylaxis, but can go as high as 80% without prophylaxis. The etiology of PONV is complex and has a multifactorial cause, including patients, anesthetic and surgical risk factors. An assessment of the PONV risk factors helps anesthesiologists to use appropriate antiemetic prophylaxis. The management of PONV includes a strategy for reducing baseline risks, administration of antiemetic prophylaxis for moderate and high risk patients, and rescue treatment if PONV prophylaxis failed. The patient‘s baseline risk should be objectively assessed using a validated risk score with known predictors. The incidence of PONV predicted by predictive models has moderate accuracy. Althoughcurrent predictive models for PONV are practical tools in PONV risk stratification, a more individual approach to each patient is needed to identify patients with more severe PONV. Anesthesiologists\u27 clinical experience and knowledge on the efficacy and safety of pharmacological and non-pharmacological antiemetic methods improve a patient satisfaction, while reducing postoperative morbidity and medical costs. New research on the role of genes in the response to antiemetic agents suggests that PONV prophylaxis and treatment could be tailored for each patient individually

Transient paraplegia after esophagectomy in a patient with thoracic epidural analgesia

Paraplegia is a rare but devastating complication in esophageal surgery. Epidural analgesia is considered essential in perioperative management of patients with esophageal cancer but carries a risk of causing neurologic deficit. We present a case of sudden postoperative paraplegia and numbness of lower extremities followed shortly after with hypotension and loss of consciousness in a 47-year old patient who underwent total esophagectomy and esophagogastroplasty with thoracic epidural analgesia. Paraplegia was short-lived and resolved with hemodynamic stabilization. We discuss possible causes of neurologic deficit in this patient and emphasise the importance of maintaining spinal cord perfussion pressure by avoiding perioperative hypotension

VATS lobectomy at theWard of Zadar Genereal Hospital

VATS (video assisted thoracoscopic surgery) lobektomija je u osnovi zahvat identičan onom koji se izvodi kroz torakotomiju. To uključuje individualnu ligaturu krvnih žila i bronha, te disekciju limfnih čvorova medijastinuma. Indikacije i kontraindikacije za VATS lobektomiju iste su kao i one za otvorenu lobektomiju. U petogodišnjem preživljenju između VATS lobektomije i otvorene lobektomije za bolesnike u 1. i 2. stadiju bolesti nema razlike. Prva VATS lobektomija na Odsjeku za torakalnu kirurgiju OB Zadar izvršena je u listopadu 2012. Od tada do 31. 12. 2013. napravljeno je 18 VATS lobektomija i 48 lobektomija kroz „muscle sparing“ torakotomiju. Usporedili smo onkološke (radikalnost zahvata, broj odstranjenih limfnih čvorova medijastinuma) i perioperativne (potrošnja analgetika i antibiotika, trajanje drenaže, brzina oporavka, trajanje hospitalizacije, broj komplikacija) parametre ova dva pristupa. Kod bolesnika koji su operirani minimalno invazivno nije bilo perioperativnog mortaliteta, trajanje drenaže bilo je u prosjeku 3 (2-5) dana, a trajanje hospitalizacije prosječno 5 (4-7) dana. Prosječan broj odstranjenih limfnih čvorova medijastinuma VATS tehnikom nije se razlikovao od broja limfnih čvorova odstranjenih otvorenom tehnikom. VATS lobektomija je pouzdana metoda operacijskoga liječenja karcinoma pluća. Nema razlike u onkološki važnim parametrima između VATS lobektomije i otvorenoga pristupa, dok su prednosti operacijskoga pristupa na strani VATS lobektomije: manji postoperacijski bolovi, manja potrošnja analgetika, pogotovo opijatnih, manja je incidencija kroničnih posttorakotomijskih bolova, imunološki sistem je manje narušen, manja je incidencija postoperativne pneumonije, kraće je trajanje hospitalizacije, veći je postotak bolesnika koji dovrše adjuvantnu kemoterapiju.VATS (video assisted thoracoscopic surgery) lobectomy is basically an operation identical to the one performed through thoracotomy. It includes individual ligature of the blood vessels and a dissection of the lymph nodes of the mediastinum. Indications and counter indications for VATS lobectomy are the same as the ones for open lobectomy. There are no differences in the five-year survival between VATS lobectomy and open lobectomy for patients in the first and second stage of the disease. The first VATS lobectomy in the Thoracic Surgery Ward was performed in October, 2012. 18 VATS lobectomies and 48 lobectomies through “muscle sparing” thoracotomy were performed from then to December 31, 2013. We compared the oncologic (radicality of the operation, number of removed lymph nodes of the mediastinum) and perioperative parameters (consumption of analgetics and antibiotics, drainage duration, recovery speed, hospitalization duration, number of complications) of these two approaches.There was no mortality with patients that underwent minimum invasive surgery. Drainage lasted on average 3 (2-5) days and hospitalization on average 5 (4-7) days. The average number of removed lymph nodes of the mediastinum using the VATS technique did not differ from the number of lymph nodes removed with open technique. VATS lobectomy is a reliable method of surgery in treating lung cancer. There is no difference in parameters of oncologic importance between VATS lobectomy and the open approach while the advantages of a surgical approach is in VATS lobectomy: less post-operative pain, lower consumption of analgetics particularly opiates, less chronic post-thoracotomic pain incidence, less disrupted immunology system, lower incidence of post-operative pneumonia , shorter hospitalization duration, higher percentage of patients who underwent adjuvant chemotherapy

Surgery treatment of pleural empyema with minimally invasive method at the Thoracic Surgery Department in Zadar General Hospital

VATS ("video assisted thoracoscopic surgery"- video-asistirana torakoskopska kirurgija) dekortikacija je metoda izbora u liječenju empijema pleure u 2. stadiju (fibrinopurulentna faza). Prednost je minimalno invazivna tehnika u već iscrpljenog bolesnika, kada su ostale metode liječenja zakazale. Kada empijem traje do tri tjedna, torakoskopska operacija je najčešće uspješna. Kada traje dulje od tri tjedna, mogućnost izvođenja dekortikacije pluća ovom metodom je znatno otežana zbog čvrstih priraslica i čvrste kožure koja obavija pluća. U takvoj situaciji konverzija u torakotomiju može biti neophodna za dovršenje zahvata. Na Odsjeku za torakalnu kirurgiju OB Zadar, u razdoblju od 1. 1. 2012. do 31. 12. 2013. od empijema pleure operirano je 32 bolesnika. Indikacija za operacijsko liječenje bila je empijem pleure kod kojega su ostale metode liječenje (antibiotici, drenaža prsišta) zakazale. Od 32 operirana bolesnika, 17 ih je operirano minimalno invazivnom metodom, dok je njih 15 podvrgnuto "muscle sparing" torakotomiji. Dvije operacije započete su minimalno invazivnom metodom, ali su zahvati dovršeni torakotomijom. Kod bolesnika koji su podvrgnuti VATS dekortikaciji nije bilo smrtnih ishoda, niti perioperativnih komplikacija, prosječno trajanje drenaže bilo je 3 dana (2-4). Prosječno trajanje hospitalizacije bilo je 5 dana (4-8). U skupini bolesnika koji su operirani klasičnim pristupom nije bilo značajnijih komplikacija niti smrtnih ishoda. Prosječno trajanje hospitalizacije u ovoj skupini bolesnika bilo je 9 dana (7-14), a prosječno trajanje drenaže 4 dana (3-6). VATS dekortikacija pluća je dokazano uspješna u liječenju empijema pleure. Vrijeme koje je proteklo od početka bolesti do torakokirurškog liječenja je najpouzdaniji prediktor uspješnosti VATS dekortikacije. Principi otvorene dekortikacije trebaju se slijediti i kod minimalno invazivne tehnike. VATS dekortikacija smatra se uspješnom kada je odstranjen sav sadržaj iz prsne šupljine, fisure otvorene, pluća oslobođena od priraslica s ošitom i prsnom stjenkom, a pluća se mogu u potpunosti ekspandirati. Postotak uspješnosti je visok, a trajanje drenaže, duljina hospitalizacije, postoperativni bolovi i oporavak su poboljšani u odnosu na otvorenu metodu.VATS ("video assisted thoracoscopic surgery"- is a decortication method of choice in treating pleural empyema in the 2nd phase (fibrinopurulent phase). The preference is a minimally invasive technique in the already exhausted patient when other treatment methods have failed. Thoracoscopic surgery is most often successful when empyema lasts for about 3 weeks. When empyema lasts longer than 3 weeks, the possibility of performing lung decortation with this method is quite more difficult due to firm adhesions that envelops the lungs and a firm cordis. In such a situation, the conversion to thoracotomy may be inevitable in order to complete the surgery. In the period from January 1, 2012, to December 31, 2013, at the Thoracic Surgery Department of Zadar General Hospital surgery was performed on 32 patients with pleural empyema. The indication for surgery treatment was pleural empyema where other methods of treatment (antibiotics, chest drainage) had failed. Among the 32 patients that had undergone surgery, the minimally invasive method was performed in 17 patients while "muscle sparing" thoracotomy was performed in 15 patients. Two of the surgeries started with the minimally invasive method but ended in thoracotomy. There were no fatal outcomes with patients that had undergone VATS decortication and there were no perioperative complications. The average drainage duration was 3 days (2-4). The average hospitalization period was 5 days (4-8). There were no significant complications and no fatal outcomes with patients that had undergone classical surgery. The average hospitalization period with this group of patients was 9 days (7-14), and average drainage duration was 4 days (3-6). VATS lung decortication has been proved successful in treating pleural empyema. The time that elapses from the beginning of the disease up to thoracic surgery treatment is the most reliable predictor of VATS decortications success. The principles of open decortication are to be followed even with the minimally invasive method. VATS decortication is considered to be successful when the entire content from the chest cavity has been removed, fissures opened, lungs free of adhesions on the diaphragm and the chest wall and lungs fully expanded. The success percentage is high and the drainage duration, hospitalization duration, postoperative pain and recovery have improved with regard to the open method

Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery

Study objective: To assess the efficacy of intraoperative different inspired oxygen fractions (FIO2) of 0.8 and 0.5 when compared with standard FIO2 0.3 in prevention of postoperative nausea and vomiting (PONV). Design: A prospective, controlled, randomized, double-blind study. Setting: General hospital, postanesthesia care unit (PACU) and gynecologic floor room. Patients: 120 ASA physical status I and II women, aged 21 to 76 y, undergoing elective gynecologic laparoscopic surgery. Interventions: Patients were randomized to receive gas mixture of 30% oxygen in air (FI O2=0.3, group G30), 50% oxygen in air (FIO2=0.5, group G50) or 80% oxygen in air (FIO2=0.8, group G80), n=36 in each group. A standardized sevoflurane general anesthesia, postoperative pain management and antiemetic regimen were used. Measurements: The incidence of nausea, vomiting or both was assessed for early (0-2h) and late PONV (2-24h) along with the use of rescue antiemetic, degree of nausea and severity of pain. Main results: There was no overall difference in the incidence of PONV at early and late assessment periods among the three groups. Patients in G80 had significantly less vomiting than G30 at 2 hours, 3% (1/36) vs. 22% (8/36), respectively, P=0.028. Nausea scores, rescue antiemetic use, pain scores and opioid consumption were not different among the groups. Conclusion: High intraoperative FIO2 of 0.8 and FIO2 of 0.5 does not prevent PONV in patients without antiemetic prophylaxis. Intraoperative FIO2 of 0.8 has beneficial effect on early vomiting only

The Role of Videomediastinoscopy in Staging of Non-Small Cell Lung Cancer

Lung cancer is the most frequent malignant disease and the leading cause of death from malignant diseases in the world and its incidence is increasing. At the time when diagnosis is established most patients have advanced disease and are not candidates for radical surgical treatment. Patients without distant metastases are subjected to various diagnostic methods to detect metastases in mediastinal lymph nodes that make up the path of lymph drainage from the lungs. The most reliable invasive diagnostic procedures for detecting metastases in mediastinal lymph nodes are videomediastinoscopy and endobronchial ultrasound with transtracheal puncture. In the absence of mediastinal lymph node metastases surgery is the treatment of choice. If mediastinal lymph nodes are positive for metastases multimodal treatment is implemented. At the Department of Thoracic Surgery, Zadar General Hospital, videomediastinoscopy for the staging of primary non-small cell lung cancer has been performed routinely since September 2009

Zbrinjavanje bolesnika s masivnim krvarenjem u Općoj bolnici Zadar

Zbrinjavanje politraumatiziranih bolesnika i bolesnika s hemoragijskim šokom predstavlja stručni i organizacijski izazov za osoblje hitnih službi. Preživljavanje takvih bolesnika ovisiti će o brzoj dijagnostici, kirurškoj kontroli krvarenja i agresivnoj nadoknadi volumena krvnim pripravcima. U našem radu prikazali smo slijed postupaka zbrinjavanja bolesnika s masivnim krvarenjem, uz primjenu protokola masivne transfuzije, čime se ubrzava doprema odgovarajuće vrste i količine krvnih pripravaka, uz istovremeno smanjenje potencijalnih nuspojava. No, uvođenje takvoga protokola u praksu zahtijeva značajne organizacijske napore, te dodatnu edukaciju osoblja koje sudjeluje u zbrinjavanju ozlijeđenih bolesnika. Svi navedeni postupci prilagođeni su organizaciji, ustroju i uvjetima u Općoj bolnici Zadar, a prilog su kvalitetnijem zbrinjavanju politraumatiziranih bolesnika, kao i drugih bolesnika u hemoragijskom šoku, poput bolesnika s obilnim gastrointestinalnim krvarenjem, opstetricijskim, ginekološkim i općenito masivnim perioperacijskim krvarenjem