The Influence of Postoperative Analgesia on Systemic Inflammatory Response and Postoperative Cognitive Dysfunction after Femoral Fractures Surgery: Randomized Controlled Trial

Cilj istraživanja: Ispitati učinak postoperativno primijenjenih analgetika, epiduralno primijenjenog levobupivakaina i intravenski primijenjenog morfina, na sistemski upalni odgovor i koncentraciju IL-6 u plazmi i utvrditi je li intenzitet upalnog odgovora povezan s pojavom postoperativne kognitivne disfunkcije (POCD). Nacrt studije: Randomizirani kontrolirani pokus. Ispitanici i metode: 70 pacijenata u dobi od ≥ 65 godina koji su podvrgnuti operativnom liječenju prijeloma bedrene kosti od lipnja 2014. do rujna 2017. godine slučajnim odabirom podijeljeno je u dvije skupine po 35 ispitanika. Kod svih pacijenata primijenjena je spinalna anestezija te jedna od dviju tehnika postoperativne analgezije: PCA uz intravensku primjenu morfina ili PCEA 0,125 % levobupivakainom. Intenzitet upalnog odgovora procijenjen je određivanjem broja leukocita, DKS-a, CRP-a, fibrinogena i IL-6 iz uzoraka krvi uzetih prije i poslije operacije. Kognitivne funkcije bolesnika procijenjene su pomoću MMSE testa. Za procjenu intenziteta postoperativne boli korištena je Numerička ocjenska ljestvica, a za procjenu anksioznosti i depresije bolesnika Bolnička ljestvica za anksioznost i depresiju. Postoperativno praćenje bolesnika uključivalo je procjenu kardiorespiracijskih, gastrointestinalnih i motoričkih funkcija. Rezultati: Incidencija POCD-a bila je značajno niža u levobupivakainskoj (9 %) u odnosu na morfinsku (31 %) (p = 0,03) skupinu. Broj limfocita bio je značajno niži u levobupivakainskoj skupini 24 sata (p = 0,08) nakon zahvata. CRP je bio značajno niži u levobupivakainskoj skupini 72 sata (p = 0,03) i 120 sati poslije operacije (p = 0,04). Fibrinogen je bio značajno niži u levobupivakainskoj skupini 24 (p = 0,003) i 72 sata (p = 0,02) poslije operacije. IL-6 bio je značajno niži u levobupivakainskoj skupini 72 sata poslije operacije (p = 0,02). Jedini prediktor za pojavu POCD-a kod svih ispitanika bila je vrijednost IL-6 72 sata poslije operacije (p = 0,03). Intenzitet boli bio je značajno niži tijekom svih postoperativnih dana u levobupivakainskoj skupini (p < 0,001). Vrijednosti hemodinamskih i respiracijskih parametra bile su više u levobupivakainskoj skupini. Petog postoperativnog dana (p = 0,001) i na dan otpusta iz bolnice (p = 0,04) značajno su više bili anksiozni ispitanici na morfinu. Zaključak: Postoji značajna povezanost između epiduralne primjene levobupivakaina i smanjenja razine pojedinih upalnih biljega u plazmi ispitanika. Postoperativna PCEA 0,125 % levobupivakainom smanjuje incidenciju POCD-a, dovodi do bolje kontrole boli, pruža veću hemodinamsku i respiratornu stabilnost te smanjuje anksioznost u ispitivanoj populaciji.Objectives: To investigate the possible effect of postoperatively applied analgesics: epidurally applied levobupivacaine or intravenously applied morphine on systemic inflammatory response and the concentration of IL-6 in plasma, as well as to determine whether the intensity of inflammatory response is related to postoperative cognitive dysfunction (POCD). Study Design: Randomized controlled trial. Patients and Methods: 70 patients ≥ 65 years old who underwent femoral fracture fixation from July 2014 to September 2017 were randomly assigned to two groups (35 patients in each). All patients received spinal anesthesia and one of two techniques of postoperative analgesia: IV-PCA using morphine or PCEA using 0.125% levobupivacaine. The inflammatory response was assessed by leukocyte count, leukocyte differential count, CRP, fibrinogen, and IL-6 levels in blood samples taken before and after surgery. Cognitive functions were assessed using the Mini-Mental State Examination (MMSE). The intensity of postoperative pain was assessed using the Numerical Rating Scale (NRS). The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depression. Postoperative cardiorespiratory, gastrointestinal, and motor functions were evaluated. Results: The incidence of POCD was significantly lower in the levobupivacaine group (9%) than in the morphine group (31%) (p = 0.03). Lymphocyte count was significantly lower in the levobupivacaine group 24 hours (p = 0.08) after surgery. CRP was significantly lower in the levobupivacaine group 72 hours (p = 0.03) and 120 hours after surgery (p = 0.04). Fibrinogen was significantly lower in the levobupivacaine group 24 hours (p = 0.003) and 72 hours (p = 0.02) after surgery. IL-6 values were significantly lower in the levobupivacaine group 72 hours after surgery (p = 0.02). The only predictor of POCD in all patients was the level of IL-6 72 hours after surgery (p = 0.03). NRS scores were significantly lower during all postoperative time points in the levobupivacaine group (p < 0.001). Postoperative hemodynamic and respiratory parameters were higher in the levobupivacaine group. Patients receiving morphine were significantly more anxious on the fifth postoperative day (p = 0.001) and on the day of hospital discharge (p = 0.04) compared with patients receiving levobupivacaine. Conclusions: There is a statistically significant correlation between epidural levobupivacaine and the reduction of some inflammatory markers. PCEA using 0.125% levobupivacaine reduces the incidence of POCD, provides better analgesia, hemodynamic and respiratory stability, and reduces anxiety in the study population

The Proximal Femoral Nail Antirotation (PFNA) in the Treatment of Proximal Femoral Fractures

Proximal femoral fractures, especially in elderly persons with osteoporosis, present a challenge for the traumatologist. While the dynamic hip screw (DHS) became the implant of choice for the treatment of stable fractures, the ideal implant for the treatment of unstable fractures remains an issue. In our experience, Proximal Femoral Nail Antirotation (PFNA) is an excellent device for osteosynthesis as it can be easily inserted, it provides angular and rotational stability and allows early weight bearing on the affected limb. Between February 2007 and August 2009, 76 patents underwent the PFNA fixation for proximal femoral fractures (15 men and 61 women). Forty seven fractures were pertrochanteric, 14 subtrochanteric, 2 pathological and 5 ipsilateral trochanteric and diaphyseal fractures whereas in 8 cases the PFNA was used in reosteosynthesis. The mean age of patients was 73.4 years (range 22–91 years). The fractures were reduced on a traction table and the implant was inserted using minimally invasive technique. Four patients developed superficial postoperative wound infection. No cases of implant breakage have been recorded; there was one cut-out; delayed union was noted in three patients. The majority of patients regained their pre-injury mobility status. The PFNA is an excellent implant for stabilisation of both trochanteric and complex combination fractures as well as an exceptional device for reosteosynthesis. It is easily inserted with few intra- and postoperative complications and allows early weight bearing on the affected limb as well as quicker rehabilitation of patients

Patient satisfaction with regional anesthesia in orthopedic surgery

Background and Purpose: The patient satisfaction with perioperative care and anesthesia is important indicator of the quality of the health care system. The evaluation of the patient’s satisfaction is a necessity, and the continuous improvement of a quality is important in anesthesia nowadays. It is important to identify the reasons and the risk factors for patients dissatisfaction with anesthesiologic procedures. We conducted this study to asses determinants of regional anesthesia on patient satisfaction. Materials and methods: This was a prospective observational study which included 164 patients older than 18 years undergoing some orthopedic procedures in regional anesthesia. We noted basic characteristics of patients, important perioperative events and on the following day patients completed a specific questionnaire. Results: Most patients (152/164) were satisfied or very satisfied with the regional anesthesia. Only 11 patients were unsatisfied, and the most common reasons for dissatisfaction were urinary retention, PONV, the multiple puncture attempts and the pain on the puncture site. About 95% patients would receive regional anesthesia again and recommend this kind of anesthesia to the others. We found statistically significant percent (12%) of increasing satisfaction in previously unsatisfied patients (p < 0,001). Conclusion: Although, the satisfaction with regional anesthesia in orthopedic surgery in our institution is generally high, there are some factors which can influence on dissatisfaction rate. It is important to identify, monitor and modify them with aim of increasing the overall satisfaction rate

Dijagnostičko-terapijski pristup kompleksnoj koagulopatiji uslijed recidivirajućeg krvarenja iz mokraćnog sustava

Coagulation disorders in critically ill patients presenting with bleeding can be multicausal. The drugs applied can interfere and impair the coagulation cascade. Point-of-care (POC) coagulation assays may resolve difficult therapeutic situations in critical illness. We report on a 73-year-old critically ill male patient with massive hematuria after bladder lithotripsy. The patient was on low molecular weight heparin therapy due to recent pulmonary embolism. He was subjected to repeated surgical hemostasis which was ineffective despite massive transfusion protocol and normal standard coagulation profile. Additional POC coagulation assays were obtained and were indicative of platelet dysfunction. We revised his medical therapy and suspected the possible drug influence on platelet aggregation. After discontinuation of target drug, platelet aggregation increased whereas hematuria stopped. Coagulation disorders in intensive care unit patients are often multifactorial. Standard laboratory tests are unreliable in complex refractory bleeding and may result in inappropriate therapeutic decisions. Stepwise approach with assessment of clinical parameters, present therapy, and a combination of POC coagulation tests is the key to optimal therapeutic management.Poremećaji koagulacije kod bolesnika u jedinici intenzivnog liječenja (JIL) su često složeni. Farmakoterapija tijekom bolesti može poremetiti fiziološki proces zgrušavanja krvi. Dodatni koagulacijski testovi uz standardni dijagnostički pristup kod nastale refraktorne koagulopatije omogućuju ciljano terapijsko djelovanje i postizanje hemostaze. Bolesnik u dobi od 73 godine u JIL se prezentirao masivnim krvarenjem iz mokraćnog mjehura nakon litotripsije i uvođenja terapijske doze niskomolekularnog heparina zbog akutne plućne embolije. Podvrgnut je višestrukim pokušajima kirurške hemostaze i masivnom transfuzijskom protokolu koji nisu doveli do prestanka krvarenja. Standardni koagulacijski testovi nisu ukazivali na poremećaj hemostaze. Dodatnim testovima utvrđena je disfunkcija cirkulirajućih trombocita. Nakon isključivanja lijekova koji mogu utjecati na njihovu funkciju došlo je do oporavka trombocitne funkcije i postizanja hemostaze. Koagulacijski poremećaji kod bolesnika u JIL-u su multifaktorski. Polipragmazija kod teško oboljelih može utjecati na fiziološki proces zgrušavanja krvi. Standardni koagulacijski testovi su nedovoljno pouzdani za razrješavanje kompleksnih koagulopatija. Sveobuhvatni klinički pristup, dodatni koagulacijski testovi i uzimanje u obzir utjecaja farmakoterapije na koagulacijsku kaskadu vodi do optimalnog terapijskog pristupa i postizanja hemostaze

Short bowel syndrome in septic patients: a case report

Sindrom kratkog crijeva očituje se malapsorpcijom koja je posljedica opsežne resekcije crijeva. Duljina crijeva preostaloga nakon kirurške resekcije smatra se glavnom odrednicom ishoda u tih bolesnika. Liječenje sindroma složeno je i nalaže multidisciplinarni pristup radi smanjenja morbiditeta i mortaliteta. Ovaj prikaz opisuje 60-godišnju bolesnicu koja je podvrgnuta multiplim resekcijama crijeva, što je rezultiralo preostalim tankim crijevom duljine 30 cm postduodenalno i terminalnom jejunostomom. Njezin boravak u jedinici intenzivnog liječenja zakomplicirao se zbog razvoja respiratornog zatajenja, bilateralne pneumonije i sepse. Pacijentica je mehanički ventilirana i liječena antimikrobnim lijekovima u skladu s rezultatima mikrobioloških pretraga i antibiogramom. Inicijalno je započeta potpuna parenteralna prehrana, dok se enteralna prehrana uvodila postupno. U liječenju bolesnice sudjelovao je multidisciplinarni tim sastavljen od anesteziologa, kirurga i gastroenterologa. Nakon četiri mjeseca bolničkog liječenja pacijentica je otpuštena kući opremljena tuneliranim središnjim venskim kateterom, a parenteralna je prehrana nastavljena u kućnim uvjetima u kombinaciji s peroralnim hranjenjem.Short bowel syndrome is a global malabsorption state resulting from an inadequate length of intestine following intestinal resection. Residual bowel length is generally considered to be the primary determinant of outcome in these patients. This complex condition requires a multidisciplinary approach to reduce morbidity and mortality. In this case report we describe a 60-year-old female patient who underwent multiple bowel resections that resulted in postduodenal small intestine length of 30 cm with an end jejunostomy being formed. Her intensive care unit stay was complicated with respiratory failure, bilateral pneumonia and sepsis. She was mechanically ventilated and treated with antimicrobial agents according to microbial isolates and antibiograms. Total parenteral nutrition was started immediately after the surgery and enteral nutrition was gradually introduced. A multidisciplinary team consisting of anesthesiologists, surgeons and gastroenterologists participated in her treatment. After four months of hospital treatment the patient was discharged home equipped with a permanent tunneled central venous catheter and continued home parenteral nutrition in combination with oral feeding

The use of an ultrasound-guided popliteal block for hallux valgus surgery in a patient with myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease which affects neuromuscular transmission, causing muscle fatigue and weakness(1).The myasthenic patients are always a challenge to the anesthesiologist, because they demonstrate various responses to the neuromuscular blocking agents. The post-operative risk of respiratory failure has always been a matter of concern (2, 3). We report a successful use of the ultrasound guided popliteal block for elective foot surgery in a 46-year old woman with MG, showing that this regional anesthesia technique, by avoiding the use of neuromuscular blocking agents, provided safe care for this patient

Are we ready for end of life decisions in intensive medicine?

Cilj istraživanja: Usporediti stavove intenzivista Kliničkog bolničkog centra Osijek o kraju života u jedinicama intenzivnog liječenja (JIL) s postupanjima u praksi. Ispitanici i metode: Istraživanje se sastojalo od dva dijela: provođenje anonimne ankete među liječnicima specijalistima koji rade u JIL-u i retrospektivne analize podataka o umrlim pacijentima u 2022. godini, prikupljenih iz bolničkog informacijskog sustava (BIS). Rezultati: Anketa je pokazala da većina liječnika nije primjenjivala smjernice za unaprijeđenje palijativne skrbi u JIL-u te da postoje dileme oko etičnosti ograničenja mjera umjetnog održavanja života. Kao glavni razlozi neprovođenja smjernica bili su identificirani nedostatak pravne zaštite i strah od percepcije kolega i obitelji. Analiza podataka iz BIS-a otkrila je značajno velik broj smrti nakon neuspješne kardiopulmonalne reanimacije (KPR) u u usporedbi s ostatkom Europe, kao i nedostatak pismenog dokumentiranja odluka o neprovođenju KPR-a i izostavljanju određene mjere umjetnog održavanja života. Iako je postojao obrazac za odluku o ograničavanju mjera i postupaka umjetnog održavanja života, većina liječnika nije bila upoznata s njegovim postojanjem niti ga je ispunila. Zaključak: Navedeni rezultati ukazuju na potrebu za poboljšanjem postupanja u donošenju odluka o kraju života u JIL-u.Objectives: To compare the attitudes of intensive care physicians at Clinical Hospital Center Osijek regarding end-of-life care in intensive care units (ICUs) with actual practice. Participants and methods: The study consisted of two parts: conducting an anonymous survey among specialist physicians working in ICUs and retrospective analysis of data on deceased patients in 2022, collected from the Hospital Information System (HIS). Results: The survey revealed that the majority of physicians did not adhere to guidelines for improving palliative care in ICUs and that there were ethical dilemmas regarding the limitation of life-sustaining measures. The main reasons for non-adherence to the guidelines were identified as a lack of legal protection and fear of colleagues’ and families’ perception. Analysis of data from the HIS identified a significantly higher number of deaths following unsuccessful cardiopulmonary resuscitation (CPR) compared to the rest of Europe, as well as a lack of written documentation of decisions to withhold CPR and specific life-sustaining measures. Although there was a protocol for making decisions on life-sustaining measures limitations, the majority of physicians were unaware of its existence and did not complete it. Conclusion: These findings highlight the need for improvement in decision-making regarding end-of-life care in ICUs