KRIKOTIREOTOMIJA - HITNI PRISTUP DIŠNOM PUTU, KADA I KAKO?

Cricothyrotomy or coniotomy is an invasive emergency procedure to establish an airway for ventilation and oxygenation when other routine methods are not possible, or are contraindicated and ineffective. The indications are situations when we cannot ventilate and cannot intubate patients with severe maxillofacial trauma, edema secondary to burns of the face and airway, laryngo-hypopharyngeal obstruction of a wide range of causes such as bilateral vocal cord paralysis because of previous head and neck surgeries, endotracheal intubation, neurologic causes and laryngeal carcinomas, congenital malformations, craniofacial trauma with massive bleeding, etc. There are no absolute contraindications, while relative ones are few and include laceration of the larynx and trachea with or without retraction of the trachea in the mediastinum. In that case, tracheotomy is indicated. Cricothyrotomy is contraindicated in children. To perform the procedure, there are several techniques, i.e. standard surgical, emergency surgical procedure and percutaneous techniques. Early complications (incidence 0-54%) include bleeding, laceration of the thyroid, cricoid cartilage and tracheal rings, perforation of the rear tracheal wall, tube misinsertion, unplanned tracheostomy, wound and cartilage infection. Long-term complications include subglottic stenosis and phonation diffi culties. Cricothyrotomy is a temporary solution to obtain ventilation and oxygenation and the need for prolonged ventilation (more than 72 h) has to be replaced with tracheotomy.Krikotireotomija ili konikotomija je invazivni kirurški postupak za hitnu uspostavu dišnog puta radi ventilacije i oksigenacije, kada ostale metode nisu moguće, dostupne ili nisu učinkovite. Indikacije za zahvat su ozbiljne traume glave i vrata, edem u području lica, ždrijela i gornjeg dišnog puta različite etiologije, laringo-hipofaringealna opstrukcija zbog obostrane paralize glasnica kao posljedica neurološke bolesti, laringealnog tumora, kongenitalne malformacije, intubacije ili masivnog krvarenja ili povraćanja zbog traume glave, kada nije moguća ventilacija ni intubacija. Apsolutnih kontraindikacija za ovaj zahvat nema, dok su relativne malobrojne: laceracija larinksa i traheje s retrakcijom traheje u medijastinum ili bez nje i tad je indicirana traheotomija radi fi ksacije traheje. Krikotireotomija je kontraindicirana kod djece. Za izvođenje zahvata postoji nekoliko tehnika: standardna kirurška tehnika, hitni kirurški postupak i perkutana tehnika. Učestalost komplikacija varira, a među rane (incidencija varira od 0 % do 54 %) možemo ubrojiti krvarenje, laceraciju tireoidne i krikoidne hrskavice ili trahealnih prstena, laceraciju stražnje stijenke traheje i proboj jednjaka, postavljanje kanile u pretrahealni prostor. Moguće kasne komplikacije su subglotična stenoza i poremećaji govora. rikotireotomiju treba prihvatiti kao hitni pristup dišnom putu, a u slučaju daljnje potrebe za prolongiranom ventilacijom (duže od 72 sata) neophodno ju je zamijeniti traheotomijom

Videolaryngoscopy, the Current Role in Airway Management

Videolaryngoscopy has emerged not only as an alternative to direct laryngoscopy for airway intubation in adults and children but also as a new diagnostic and therapeutic tool in head and neck surgery. Videolaryngoscopy has a great advantage over direct laryngoscopy because it has been proven to reduce difficult views of the laryngeal opening (glottis). The success of intubation with a videolaryngoscope depends on both the type of device used and the experience of the operator. Technical details, such as the device’s size and blade choice, properly reshaping the endotracheal tube, and customized hand-eye coordination, are all particularly important for targeting the endotracheal tube toward the glottis. Besides its clinical role in airway management, videolaryngoscopy is an excellent tool for education and medicolegal recording

Alternativni uređaji za intubaciju

The Macintosh laryngoscope has been the most widely used device for intubation since its invention by Foregger in the 1940s. Recently, video and optic laryngoscopy assisted tracheal intubation has been used widely in patients with difficult airways. Their routine use, however, is not widely practiced. This review will summarize some of the newly available devices to assist tracheal intubation, with their advantages and disadvantages when compared with conventional laryngoscopes. It also presents the reasons to support their use in both elective and emergency airway management.Macintoshov laringoskop je najčešće korišteni uređaj za intubaciju koji je prvi puta primijenio Foregger 1940. godine. Kasnije su uvedeni video i optički laringoskopi koji pomažu pri intubaciji u bolesnika s otežanim dišnim putem. Međutim, njihova rutinska uporaba nije široko prihvaćena u praksi. U ovom članku se sažeto iznose prednosti i nedostaci novih dostupnih uređaja koji pomažu tijekom intubacije u usporedbi s konvencionalnim laringoskopima. Dodatno se iznose razlozi za uporabu novih uređaja kod elektivnog i hitnog zbrinjavanja dišnoga puta

Izazovi u uporabi video laringoskopa

Despite the lack of uniformity and the need of further investigation, video laryngoscopy continues to gain popularity both inside and outside the operating room. It has quickly become a first line strategy for potential and/or encountered difficult intubation. It is well established that video laryngoscope improves laryngeal view as compared with direct laryngoscopy in patients with suspected difficult intubation and simulated difficult airway scenarios. For novices and experienced anesthesiologists alike, video laryngoscopy is easy to use and the skills involved are easy to master. However, it is important to say that video laryngoscopes may be used in a variety of clinical scenarios and settings because of the video laryngoscope design offering an alternative intubation technique in both anaesthetized and awake patients. The aim of this article is to show and highlight clinical situations in which the use of video laryngoscope is a challenge for an experienced anesthesiologist in solving the airway. Challenges in the use of video laryngoscope with which we deal and encounter in everyday clinical practice that are discussed in this paper are intubation in the prehospital setting and emergency departments, intubation in Intensive Care Unit, intubation in a patient with cervical spine immobilization, and awake video laryngoscopy-assisted tracheal intubation in the obese. We also point out the important role of video laryngoscope as a tool for teaching and training in airway education. Training and education in difficult airway management is essential to improve patient safety at endotracheal intubation in emergency situation.Unatoč nedostatku ujednačenosti proizvoda na tržištu i potrebe za daljnjim istraživanjem, video laringoskopi i dalje su popularni unutar i izvan operacijske dvorane. Oni su postali prva linija u strategiji za potencijalne i/ili teške intubacije. Dobro je poznato da video laringoskopi poboljšavaju prikaz larinksa u usporedbi s direktnom laringoskopijom u bolesnika sa sumnjom na otežanu intubaciju i kod simuliranih teških pristupa dišnome putu. Za početnike i iskusne anesteziologe podjednako video laringoskop je jednostavan za korištenje, a vještine koje su potrebne za rad s njim su lako savladive. Osobitost video laringoskopa je da se može koristiti u različitim kliničkim situacijama s obzirom na to da su osmišljeni tako da nude alternativnu tehniku i u anesteziranih i kod budnih bolesnika. U ovom radu želimo ukazati na kliničke situacije u kojima korištenje video laringoskopa predstavlja izazov za iskusne anesteziologe u rješavanju otežanoga pristupa dišnome putu. Specifične indikacije za korištenje video laringoskopa u svakodnevnoj kliničkoj praksi su: intubacija u pre-hospitalnim uvjetima i hitnim odijelima; intubacija u jedinici intenzivnog liječenja; intubacija bolesnika s imobiliziranom vratnom kralježnicom te budna intubacija u pretilih bolesnika. U radu također ističemo važnu ulogu laringoskopa u edukaciji prikaza i tehničkog savladavanja pristupa dišnome putu. Obuka i obrazovanje u zbrinjavanju otežanoga dišnog puta je nužna radi poboljšanja sigurnosti bolesnika u hitnim stanjima kod kojih je neophodna uspostava dišnoga puta

Regional anaesthesia in cancer surgery: an update

Anaesthetic techniques can influence the cellular immune system and affect long term outcome. Cancer surgery itself and general anaesthetics, especially opioids, suppress immunity and therefore promote metastases. Regional anaesthesia attenuates the immunosuppressive effect of surgery. Local anaesthetics, contrary to opioids, stimulate the activity of natural killer (NK) cells during the perioperative period. All techniques of regional anaesthesia are very useful and applicable in cancer surgery, either for the anaesthesia itself or for the treatment of postoperative pain. The relationship between regional anaesthesia and cancer recurrence is one of the most interesting topics in anaesthesia today, but we must wait the results of prospective trials before definitive conclusions

Smjernice zbrinjavanja dišnog puta u porodiljstvu

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.Anatomske i fiziološke promjene tijekom trudnoće čine uspostavu sigurnoga dišnog puta u trudnica u slučaju potrebe operativnog zahvata u općoj anesteziji težim nego što je to u neopstetričkoj populaciji. Nemogućnost ventilacije i oksigenacije jedan je od najčešćih uzroka pobola i smrtnosti povezanih s općom anestezijom za carski rez. Cilj ovoga rada je prikazati i analizirati suvremene smjernice i algoritme uspostave otežanoga dišnog puta u porodiljstvu kao važnom segmentu anesteziološke prakse. Suvremene smjernice zbrinjavanja dišnog puta u trudnica opisuju postupak otežane ventilacije na masku, otežanog zbrinjavanja dišnog puta primjenom supraglotičkih pomagala, otežanu endotrahealnu intubaciju te hitnu krikotirotomiju ili traheotomiju u situaciji nemoguće oksigenacije i ventilacije. Algoritmi opisuju postupke i opremu za svaku varijantu otežanog dišnog puta te strategije odlučivanja i situacije kada se dišni put, kao ni dostatna oksigenacija, ne uspijevaju osigurati. Hrvatski anesteziolozi u većini opstetričkih odjela raspolažu odgovarajućom opremom, kao i potrebnim iskustvom u zbrinjavanju otežanoga dišnog puta u trudnica te se suvremeni algoritmi najrazvijenijih zemalja mogu usvojiti i prilagoditi našoj dnevnoj praksi te ugraditi u kurikule izobrazbe specijalizanata

Strateški pristup ekstubaciji nakon otežane intubacije

Airway management relates to the period of tracheal intubation, maintenance of endotracheal tube in situ, and finally extubation. Problems related to difficult extubation still pose significant challenge for both anesthesiologists and intensivists. This article reviews current approach to extubation strategy following difficult intubation. Guidelines and algorithm may be helpful in order to ensure safe management of the patient during this delicate period of airway management.Osiguravanje dišnog puta odnosi se na razdoblje intubacije, održavanje endotrahealnog tubusa in situ i konačno na razdoblje ekstubacije. Problemi u vezi s otežanom ekstubacijom još uvijek predstavljaju značajan izazov za anesteziologe i intenziviste. Ovaj članak prikazuje suvremeni strateški pristup ekstubaciji nakon otežane intubacije. Smjernice i algoritmi mogu biti korisni za održavanje sigurnosti bolesnika u tom osjetljivom razdoblju osiguravanja dišnog puta

THE IMPORTANCE OF ANESTHESIA IN DIAGNOSTIC TESTS OF ENDOBRONCHIAL ULTRASOUND

Prikazan je mogući anestezijski postupak za dijagnostički endobronhijski ultrazvuk. (EBUS). EBUS je specifi čna pretraga za dijagnostiku novonastale hilarne i/ili medijastinalne limfadenopatije te tumora pluća. Anestezija olakšava izvođenje ovog dijagnostičkog postupka bolesniku i liječniku. Iz dosadašnjih studija vidljivo je da su u primjeni različite tehnike anestezije. Postupak se može izvesti u sedaciji primjenom lokalnog anestetika i općoj anesteziji. Kod primjene sedacije lokalnim anestetikom bolesnik diše spontano, a u općoj anesteziji se dišni put održava laringealnom maskom ili orotrahealnim tubusom. Bolesniku u dobi od 57 godina, tjelesne težine (TM) 94 kg, ASA I (The American Society of Anesthesiologists), uredne plućne funkcije, bez poznatih alergija, indicirana je dijagnostička pretraga EBUS zbog povećanih limfnih čvorova u medijastinumu. Dijagnostička pretraga EBUS izvodi se na udaljenom radilištu koji je opremljen anesteziološkim uređajem Datex-Ohmeda S5 Aespire 1990. godine i monitorom Philips IntelliVue MP60. te smo anestezijski postupak prilagodili postojećim uvjetima. Monitorira se srčana frekvencija, elektrokardiogram (EKG), broj respiracija, krvni tlak, te postotak zasićenja hemoglobina kisikom pulsnim oksimetrom. Postavljena je intravenska kanila čija se prohodnost održava infuzijom 500 mL 0,9 % NaCl. Nakon lokalne anestezije 1-2 mL 1 %-tnim lidokainom orofaringealnog područja bolesnik je sediran midazolamom (2,5 mg), n-fentanilom (5 mcg) te propofolom (bolus 100 mg i doza održavanja kontinuirano 4 mg /min). Nakon fl eksibilne bronhoskopije kroz nos od 5 minuta nastavlja se EBUS kroz usnik u trajanju od 22 minute. Dijagnostički postupak ukupno je trajao 27 minuta. Za vrijeme anestezije bolesnik je bio respiracijski i hemodinamski stabilan, diše spontano uz suplementaciju smjese zrak/kisik 1 : 1 volumnim modalitetom maksimalnog volumena 700 mL i frekvencije maksimalno 33/min. S takvom modifi - kacijom se postigla zadovoljavajuća ventilacija i zasićenost kisikom koja je na periferiji iznosila 94±4 %. Sistolički krvni tlak je iznosio 157±7 mm Hg, a dijastolički 78±9 mm Hg. Srčana frekvencija bila je 88±8/min. Bolesnik se nakon učinjenog dijagnostičkog zahvata uredno probudio. Anestezija je protekla bez komplikacija.A possible anesthetic procedure for diagnostic endobronchial ultrasound (EBUS) is presented. EBUS is a specifi c search for the diagnosis of newly emerged hilar and/or mediastinal lymphadenopathy and lung tumors. Anesthesia facilitates the performance of this diagnostic procedure for the patient and the physician. From previous studies, it is apparent that various anesthetic techniques are employed. The procedure can be performed in sedation with the application of local anesthetic and general anesthesia. When using local anesthetic sedation, the patient breathes spontaneously, general anesthesia maintains the respiratory tract with a laryngeal mask or an orotracheal tube. In the patient aged 57, body mass 94 kg, with regular pulmonary function according to ASA classifi cation, without known allergies, the EBUS diagnostic scan was indicated for increased lymph nodes in the mediastinum. Diagnostic EBUS is run on a remote site equipped with the Datex-Ohmeda S5 Aespire anesthetic device and the Philips IntelliVue MP60 monitor, and we adjusted the anesthetic process to the existing conditions. Heart rate, electrocardiogram, number of breaths, blood pressure, percentage of hemoglobin, oxygen saturation and pulse oximetry were monitored. Intravenous cannula was placed and infusion of 500 mL of 0.9% NaCl maintained. Following local anesthesia with 1-2 mL 1% lidocaine in the oropharyngeal area, the patient was sedated with midazolam (2.5 mg), n-fentanyl (5 mcg) and propofol (bolus 100 mg and continuous maintenance dose of 4 mg/min). After fl exible bronchoscopy through the nose for 5 min, the EBUS was continued through the mouth for 22 min. The diagnostic procedure took a total of 27 min. During anesthesia, the patient was respiratory and hemodynamically stable. The patient breathed spontaneously with the addition of air/oxygen mixture 1:1, with a modality of 700 mL maximum volume and maximum frequency of 33/min. Such modifi cation achieved satisfactory ventilation and oxygen saturation at the periphery of 94±4%. Systemic blood pressure was 157±7 mm Hg and diastolic pressure 78±9 mm Hg. Heart rate was 88±8 min. After completing the diagnostic procedure, the patient woke up neatly. Anesthesia was without complications

Procjena standardnih antropometrijskih obilježja dišnoga puta u bolesnika sa sindromom opstrukcijske apneje pri spavanju za kirurgiju poremećaja disanja pri spavanju: retrospektivno istraživanje u jednom kliničkom centru

The aim of this study was to explore standard anthropometric airway characteristics of patients with obstructive sleep apnea syndrome (OSAS) and determine the incidence and risk factors for difficult airway management. Final analysis included 91 patients with polysomnography- verified diagnosis of OSAS who underwent sleep breathing disorder surgery under general anesthesia with direct laryngoscopy oroendotracheal intubation. The incidence of difficult manual mask ventilation during anesthesia induction, difficult intubation and immediate postextubation respiratory complications was 17.6%, 7.7% and 7.7%, respectively. Compared to patients without difficult manual mask ventilation, the group of OSAS patients with difficult manual mask ventilation had a higher rate of body mass index (BMI) ≥25 kgm-2 (p=0.010), Mallampati score ≥3 (p=0.024) and Cormack-Lehane score ≥3 (p=0.002). The OSAS patients with difficult intubation had more Cormack-Lehane score ≥3 (p=0.002) in comparison to those without difficult intubation. Our study demonstrated that manual mask ventilation during anesthesia induction was the most troublesome airway management task in OSAS patients during sleep breathing disorder surgery. Cormack-Lehane score was a relevant determinator of difficult mask ventilation and difficult intubation, while Mallampati score and BMI were relevant determinators only for difficult manual mask ventilation.Cilj ovoga istraživanja bio je odrediti standardna antropometrijska obilježja dišnoga puta u bolesnika sa sindromom opstruktivne apneje pri spavanju (OSAS), utvrditi incidenciju i rizične čimbenike zbrinjavanja otežanoga dišnog puta. Završna analiza je uključivala 91 bolesnika s potvrđenom dijagnozom OSAS polisomnografijom, koji su bili podvrgnuti kirurškom zahvata poremećaja disanja kod spavanja u općoj anesteziji s oroendotrahealnom intubacijom. Učestalost otežane manualne ventilacije maskom tijekom uvoda u anesteziju, otežane intubacije i neposredne poslijeekstubacijeke komplikacije su bile slijedom 17,6%, 7,7% i 7,7%. U usporedbi s bolesnicima bez otežane manualne ventilacije maskom skupina bolesnika s OSAS i otežanom manualnom ventilacijom na masku je češće imala indeks tjelesne mase ( ITM) ≥25 kgm-2 (p=0,010), Mallampatijevu ocjenu ≥3 (p=0,024) i Cormack- Lehaneovu ocjenu ≥3 (p=0,002). Bolesnici s OSAS i otežanom intubacijom su češće imali Cormack-Lehaneovu ocjenu ≥3 (p=0,002) u usporedbi s onima bez otežane intubacije. Naše istraživanje je pokazalo da je najproblematičniji zadatak zbrinjavanja dišnoga puta u bolesnika podvrgnutih kirurgiji poremećaja disanja kod spavanja manualna ventilacija na masku tijekom uvoda u anesteziju. Cormack-Lehaneova ocjena je relevantni rizični čimbenik za otežanu ventilaciju na masku i otežanu intubaciju, dok su Mallampatijeva ocjena i ITM bili relevantni rizični čimbenici samo za otežanu ventilaciju na masku