Poslijeintubacijske ozljede traheje: prikazi slučajeva i pregled literature

Post-intubation tracheal injury is a rare and potentially fatal complication. The most common causes are overinflation of endotracheal tube cuffs and multiple intubation attempts in emergency cases. The diagnosis is based on clinical and radiological suspicion of tracheal injury confirmed by fiberoptic bronchoscopy. Decision between conservative and surgical management of the injury depends on clinical presentation (respiratory instability, concomitant diseases), lesion characteristics (lesion site, size, and number), and time elapsed from injury to diagnosis. We present three cases of post-intubation tracheal injury. In two cases, the patients were treated conservatively; in the third case, the patient died from asphyxia caused by thrombus occlusion of the trachea after a longitudinal tracheal lesion. Pre-anesthetic examination did not indicate any possibility of difficult intubation in any of the patients; however, in one of the patients admitted through the emergency department, emergency intubation was performed.Poslijeintubacijska ozljeda traheje je rijetka i potencijalno fatalna komplikacija. Najčešći uzroci ozljeda su prenapuhnuti balončić tubusa i višekratni pokušaji intubacije u hitnim slučajevima. Dijagnoza se temelji na kliničkoj i radiološkoj sumnji koja se potvrđuje fiberoptičkom bronhoskopijom. Odluka o konzervativnom ili kirurškom zbrinjavanju ozljede ovisi o kliničkoj slici bolesnika (respiracijskoj nestabilnosti, pratećim bolestima), značajkama ozljede (mjestu, duljini i broju oštećenja) i vremenu koje je proteklo između trenutka oštećenja i postavljanja dijagnoze. Prikazujemo troje bolesnika s poslijeintubacijskom ozljedom traheje, dvoje od njih liječeni su konzervativno, a jedna je bolesnica preminula zbog asfiksije izazvane začepljenjem traheje ugruškom nastalim nakon longitudinalne lezije. Niti u jednog od njih u prijeoperacijskom anesteziološkom pregledu ništa nije ukazivalo na moguću otežanu intubaciju, osim što je jedan bolesnik zaprimljen i operiran kao hitan slučaj

Poslijeintubacijske ozljede traheje: prikazi slučajeva i pregled literature

Post-intubation tracheal injury is a rare and potentially fatal complication. The most common causes are overinflation of endotracheal tube cuffs and multiple intubation attempts in emergency cases. The diagnosis is based on clinical and radiological suspicion of tracheal injury confirmed by fiberoptic bronchoscopy. Decision between conservative and surgical management of the injury depends on clinical presentation (respiratory instability, concomitant diseases), lesion characteristics (lesion site, size, and number), and time elapsed from injury to diagnosis. We present three cases of post-intubation tracheal injury. In two cases, the patients were treated conservatively; in the third case, the patient died from asphyxia caused by thrombus occlusion of the trachea after a longitudinal tracheal lesion. Pre-anesthetic examination did not indicate any possibility of difficult intubation in any of the patients; however, in one of the patients admitted through the emergency department, emergency intubation was performed.Poslijeintubacijska ozljeda traheje je rijetka i potencijalno fatalna komplikacija. Najčešći uzroci ozljeda su prenapuhnuti balončić tubusa i višekratni pokušaji intubacije u hitnim slučajevima. Dijagnoza se temelji na kliničkoj i radiološkoj sumnji koja se potvrđuje fiberoptičkom bronhoskopijom. Odluka o konzervativnom ili kirurškom zbrinjavanju ozljede ovisi o kliničkoj slici bolesnika (respiracijskoj nestabilnosti, pratećim bolestima), značajkama ozljede (mjestu, duljini i broju oštećenja) i vremenu koje je proteklo između trenutka oštećenja i postavljanja dijagnoze. Prikazujemo troje bolesnika s poslijeintubacijskom ozljedom traheje, dvoje od njih liječeni su konzervativno, a jedna je bolesnica preminula zbog asfiksije izazvane začepljenjem traheje ugruškom nastalim nakon longitudinalne lezije. Niti u jednog od njih u prijeoperacijskom anesteziološkom pregledu ništa nije ukazivalo na moguću otežanu intubaciju, osim što je jedan bolesnik zaprimljen i operiran kao hitan slučaj

Effect of postoperative pain therapy on surgical outcome

Although efficient treatment of post-surgical pain is considered to be a pre-condition for a normal course of the post-surgical period, epidemiological and clinical research show that a significant number of patients still suffer intense pain after major surgery. Intense nociceptive somatic and visceral post-surgical pain has in the last ten years been considered the most important development of endocrine and neurohumoral disorders in the immediate post-surgical period, (the vital organ functional disorders, occurence of serious ostoperative complications and prolonged hospitalisation.) The effects of successful perioperative analgesia on the course and outcome of surgical patients remains disputable, particularly because there is no consensus on the optimal procedure for specific pain therapy. The multimodal analgesia (defined as use of NSAIDs, COX–2 inhibitors or paracetamol in combination with i.v. opioid PCA ) results in an opioid sparing effect. However, this opioid reduction does not consistently result in decreased opioid side effects. The overall negative outcome effects by i.v. opioids PCA correspond well with minor effects on postoperative dynamic pain, stress response and organ dysfunctions. At present the entire role of perioperative epidural technique on patient outcome is unclear. Also, the advantages of epidural analgesia have to be balanced against their risk and cost. The concept of multi-modal analgesia is an area of most importance and where future research efforts should focus on the combination of several techniques such as continuous peripheral nerve-blocks, continuous wound-infusion of local anaesthetics, NSAIDs/COX-2 inhibitors, paracetamol, α-2 agonists, ketamine, dextromethorphane, gabapentin/pregabalin, glucocorticoids etc

A REPORT OF SEVERE OVARIAN HYPERSTIMULATION SYNDROME CASE IN THE ASSISTED REPRODUCTION PROCEDURE

Prikazana je primarno neplodna pacijentica s dijagnosticiranim sindromom policističnih jajnika, koja je u postupku potpomognute oplodnje stimulirana GnRh agonistom i gonadotropinima, te koja je razvila teški oblik sindroma hiperstimulacije jajnika. Stanje pacijentice se dodatno pogoršalo nakon što je nastupila trudnoća. Na odjelu intenzivne njege provela je 21 dan, u bolnici ukupno 55 dana. Trudnoća je završila porodom zdravog djeteta carskim rezom u 38. tjednu trudnoće.We present a case of a primary infertile patient with diagnosed polycystic ovary syndrome, who in an assisted reproduction procedure was stimulated with GnRh agonists and gonadotropins, and who subsequently developed a severe ovarian hyperstimulation syndrome. The patient’s condition was further worsened after the pregnancy was confirmed. She spent 21 day at the intensive care unit and 55 days in the hospital. The pregnancy resulted in the birth of the healthy child, delivered by caesarean section at 38th week of pregnancy

Acute kidney injury in perioperative settings

Acute kidney injury is a clinical syndrome which represents relevant and serious perioperative complication. It is associated with increased patient morbidity, mortality, prolonged hospital stays, and not to mention greater healthcare costs. Yet, the patients who suffered from temporary acute kidney injury in the perioperative period, and regardless of the final outcome, usually complain afterwards about emotional distress, coupled with poor quality of life associated with loss of energy and limited normal physical activity. Therefore, the role of the physician to predict a kidney vulnerable patient in the perioperative period is a task of great importance, albeit not an easy one. The key management is risk stratification of the patient in conjunction with hemodynamic and oxygen optimization, in addition to avoiding nephrotoxic agents during the entire perioperative period

Effects of epidural magnesium sulphate on intraoperative sufentanil and postoperative analgesic requirements in thoracic surgery patients

Introduction. Thoracic surgery is associated with high levels of pain. Magnesium has antinociceptive effects in animal and human models of pain. Objectives. The aim of this randomized prospective study was to assess the effects of continuous epidural magnesium infusion during thoracic surgery on intraoperative sufentanil consumption and postoperative analgesic requirements during the first 48 hours after surgery. Materials and methods. Seventy patients were randomized into two groups of 35 patients: Group 1 (magnesium group) received an epidural with 10% magnesium sulfate (MgSO4) along with anesthetic drugs (midazolam, propofol, rocuronium, sufentanil, levobupivacain), and group 2 (control group) received an epidural with 0.9% sodium chloride (NaCl) solution along with anesthetic drugs intraoperatively. Postoperatively, group 1 patients were administered the 10% magnesium sulfate epidural in addition to a local anesthetic and opioid, whereas group 2 patients were administered the local anesthetic and opioid alone. Primary outcomes of the study were to determine the cumulative doses of intraoperatively administered sufentanil and cumulative doses of sufentanil and levobupivacaine administered during the first 48 h postoperatively. Secondary outcomes were a visual analog scale (VAS) score for rest and movement every 4 hours, level of sedation, cardiovascular, respiratory and neurological complications, incidence of postoperative shivering, nausea and vomiting and global patient satisfaction. Results. The cumulative sufentanil dose required intraoperatively was significantly lower in the magnesium group: 43.00 μg vs 56.3 μg ( p = 0.001). VAS scores measured every 4 hours at rest and movement during the first 48 hours postoperatively, cumulative analgesic consumption, incidence of shivering, nausea and vomiting were significantly lower in the magnesium group. The global satisfaction score was significantly higher in the magnesium group (4.3 vs 3.7; p = 0.005). Conclusion. The addition of magnesium in the epidural mixture of sufentanil and levobupivacaine led to more efficient intraoperative and postoperative analgesia, lower sufentanil and levobupivacaine consumption, lower incidence of postoperative shivering, nausea and vomiting. Epidural with magnesium appears to be a useful adjunct to anesthetic drugs, which can exert positive effects on the course and outcome of thoracic surgery patients

A REPORT OF SEVERE OVARIAN HYPERSTIMULATION SYNDROME CASE IN THE ASSISTED REPRODUCTION PROCEDURE

Prikazana je primarno neplodna pacijentica s dijagnosticiranim sindromom policističnih jajnika, koja je u postupku potpomognute oplodnje stimulirana GnRh agonistom i gonadotropinima, te koja je razvila teški oblik sindroma hiperstimulacije jajnika. Stanje pacijentice se dodatno pogoršalo nakon što je nastupila trudnoća. Na odjelu intenzivne njege provela je 21 dan, u bolnici ukupno 55 dana. Trudnoća je završila porodom zdravog djeteta carskim rezom u 38. tjednu trudnoće.We present a case of a primary infertile patient with diagnosed polycystic ovary syndrome, who in an assisted reproduction procedure was stimulated with GnRh agonists and gonadotropins, and who subsequently developed a severe ovarian hyperstimulation syndrome. The patient’s condition was further worsened after the pregnancy was confirmed. She spent 21 day at the intensive care unit and 55 days in the hospital. The pregnancy resulted in the birth of the healthy child, delivered by caesarean section at 38th week of pregnancy