Acute Coronary Syndrome with ST-segment Elevation in Pregnancy: Anesthetic Management of Delivery

Acute coronary syndrome (ACS) during pregnancy is rare but may be associated with high risk complications. Approximately 150 myocardial infarctions (MI) during pregnancy have been documented in literature worldwide, but we didn’t find one with myocardial aneurysm. We describe 2 patients with acute MI; both with ST segment elevation (STEMI), 1 case complicated with heart failure, formation of a myocardial aneurysm and broad QRS arrhythmia; another with uncomplicated course, and their anesthetic management during delivery. Acute MI is rare in reproductive age usually developing in women with cardiovascular risk factors. There is concern about its rising incidence due to the increase of average maternal age. Our cases show that there might be some undiscovered risk factors for pregnancy related myocardial infarction

SPECIFICS OF COAGULATION AND REGIONAL ANESTHESIA IN PARTURIENTS

U nemalom broju trudnica mogu biti prisutni poremećaji koagulacijskog sustava koje je nužno poznavati s obzirom da su centralna neuroaksijalna analgezija i anestezija glavne anesteziološke tehnike u zbrinjavanju porođajne boli te boli tijekom carskog reza. Epiduralni i spinalni hematom su rijetke, ali kobne komplikacije spomenutih postupaka. U trudnica s poremećajima koagulacije potrebno je na individualnoj razini procijeniti korist te potencijalne komplikacije centralnih neuroaksijalnih blokova.Coagulation abnormalities are not uncommon during pregnancy and it is necessary to be familiar with such abnormalities because the central neuraxial blocks represent the most common technique for analgesia and anesthesia during delivery or cesarean section because epidural and spinal hematomas are severe complications of the mentioned procedures. In a parturient with coagulation abnormality, it is necessary to estimate, on individual basis, the benefi ts and risks of central neuraxial blocks

SPECIFICS OF COAGULATION AND REGIONAL ANESTHESIA IN PARTURIENTS

U nemalom broju trudnica mogu biti prisutni poremećaji koagulacijskog sustava koje je nužno poznavati s obzirom da su centralna neuroaksijalna analgezija i anestezija glavne anesteziološke tehnike u zbrinjavanju porođajne boli te boli tijekom carskog reza. Epiduralni i spinalni hematom su rijetke, ali kobne komplikacije spomenutih postupaka. U trudnica s poremećajima koagulacije potrebno je na individualnoj razini procijeniti korist te potencijalne komplikacije centralnih neuroaksijalnih blokova.Coagulation abnormalities are not uncommon during pregnancy and it is necessary to be familiar with such abnormalities because the central neuraxial blocks represent the most common technique for analgesia and anesthesia during delivery or cesarean section because epidural and spinal hematomas are severe complications of the mentioned procedures. In a parturient with coagulation abnormality, it is necessary to estimate, on individual basis, the benefi ts and risks of central neuraxial blocks

MULTI-MODAL ANALGESIA AFTER HYSTERECTOMY AND ADNEXECTOMY

Postoperativni bol je najčešći oblik akutnog bola, a nedovoljna analgezija može dovesti do niza komplikacija. Osnovni cilj našeg istraživanja bio je usporediti dvije metode analgezije multimodalnim pristupom i postići odgovarajući analgetski učinak primjenom obiju metoda. Analizirano je 50 slučajno odabranih bolesnica tijekom prvog operacijskog dana, nakon abdominalne histerektomije i adneksektomije. Prema Američkom društvu anesteziologa bolesnice su procijenjene na ASA status I-III. Kod prve skupine od 25 bolesnica, kontinuirano intravenski primijenjeni su metamizol i tramadol, a kod druge skupine od 25 bolesnica ketoprofen i tramadol. Razina boli u svih bolesnica praćena je u prvom, trećem, šestom i devetom postoperativnom satu i zabilježena u tablice pomoću vizualno analogne ljestvice (visual analogue scale – VAS). U obje skupine postignut je zadovoljavajući analgetski učinak. Bolesnice u drugoj skupini (s ketoprofenom) su ranije postigle granicu između umjerene i neznatne boli, te bi stoga, kao nesteroidni antiinflamatorni lijek prvog izbora preporučili ketoprofen kao dodatak tramadolu.Postoperative pain is the most common form of an acute pain and inadequate analgesia can lead to numerous complications. Our goal was to compare two different methods of analgesia by multimodal approach and to optimize pain control in both groups. During the first operative day, 50 randomly chosen patients undergoing abdominal hysterectomy with bilateral adnexectomy were analyzed. According to the American Society of Anesthesiologists (ASA) they were classified to Class I-III. In the first group of 25 patients, metamizol and tramadol were administered in continuous intravenous infusion and in the second group of 25 patients ketoprofen and tramadol were administered. Pain was registered during the first, third, sixth and ninth postoperative hour using visual analogue scale (VAS). In both groups the adequate level of analgesia was achieved, although the patients in the second group have reached moderate level of pain earlier than the second group did. Therefore, as the non-steriod antiiflammatory drug adjuvant to opioid drug we prefer ketoprofen to metamizole

ČIMBENICI STRESA MEDICINSKIH SESTARA U COVID ODJELIMA

Objective: To define the stressors that cause the highest level of stress in nurses / technicians in COVID intensive care units (ICU) and regular COVID departments and to compare stressors between these two departments. Methods: For the purposes of the research, a validated questionnaire on stressors at the workplace of hospital health workers was used. The questionnaires were distributed to 194 nurses/technicians, working in the COVID departments. The questionnaire consists of 3 parts; the first part contains demographic data of the respondents, the second part of the questionnaire consists of 34 questions that describe certain stress factors and are answers are offered on a Likert - type scale and the last part of the questionnaire consists of 3 open-ended questions to which respondents can add stressors to which they are exposed, which were not previously mentioned. Results: Differences were found in the level of education regarding the length of work with COVID patients, nurses / technicians with a higher level of education worked longer in the COVID department (p=0.043). No differences were found in the level of stress between nurses/technicians working in the COVID department compared to the COVID ICU (p=0.181). Among the factors that caused the highest level of stress are: work overload, inadequate personal income, insufficient number of employees and everyday unpredictable and unplanned situations. Conclusion: Our results indicate that there is no difference in the level of stress between nurses working in the COVID departments compared to nurses working in the COVID ICU. Due to the high prevalence of stress among nurses who work with COVID patients, it is necessary to monitor the symptoms of burnout and provide support in the workplace. According to the results of our research, there is a need to optimize working conditions and invest efforts in order to reduce the workload.Cilj: Definirati stresore koji na radnom mjestu u COVID jedinicama intenzivne skrbi i COVID odjelima uzrokuju najvišu razinu stresa kod medicinskih sestara/tehničara i usporediti stresore između navedenih odjela. Metode: Za potrebe istraživanja korišten je validiran upitnik o stresorima na radnom mjestu bolničkih zdravstvenih djelatnika. Upitnici su podijeljeni na 194 medicinske sestre / tehničare koji rade na COVID odjelima. Upitnik se sastoji od 3 dijela; u prvom dijelu su demografski podaci ispitanika, drugi dio upitnika sastoji se od 34 pitanja koja opisuju pojedine čimbenike stresa te su ponuđeni odgovori na skali Likertovog tipa i zadnji dio upitnika sastoji se od 3 pitanja otvorenog tipa na koje ispitanici mogu nadopisati stresore kojima su izloženi, a koji nisu prethodno spomenuti. Rezultati: Utvrđene su razlike u razini obrazovanja obzirom na duljinu rada s COVID bolesnicima, u COVID odjelu su duže radile medicinske sestre/tehničari više razine obrazovanja, P=0.043. Nisu utvrđene razlike u jačini stresa između medicinskih sestara/tehničara koje rade u COVID odjelu u odnosu u COVID JIL, P=0.181. Među čimbenicima koji uzrokuju najvišu razinu stresa su: preopterećenost poslom, neadekvatna osobna primanja, nedostatan broj djelatnika i svakodnevne nepredvidive i neplanirane situacije. Zaključak: Naši rezultati pokazuju da nema razlike u razini stresa između sestara koje rade u COVID odjelima u usporedbi s medicinskim sestrama koje rade u COVID JIL-u. Zbog visoke prevalencije stresa među medicinskim sestrama koje rade s COVID bolesnicima potrebno je pratiti simptome sagorijevanja i pružiti podršku na radnom mjestu. Prema rezultatima našeg istraživanja, postoji potreba za optimizacijom radnih uvjeta i ulaganjem napora u cilju smanjenja radnog opterećenja

THERAPEUTIC MECHANISMS OF KETAMINE

Major depressive disorder is the greatest burden of developed countries in the context of morbidity caused by mental disorders. Until recent, ketamine has been mostly used for anesthesia, analgesia, sedation and treatment of chronic pain syndromes. However, unique pharmacodynamic properties of ketamine have increased interests in it\u27s use for treatment of depression. It is assumed that ketamine reverses synaptic chronic stress pathology within one day of administration by postsynaptic glutamate activation, providing synaptic connectivity restoration that last for days or weeks. Potential glutamatergic agents, in context of treatment of major depressive disorder are not entirely novel phenomenon. Considering the aforementioned, current neurobiological view of depression as a solely monoaminergic phenomenon should be reassessed in order to prompt discovery of putative antidepressant drugs of novel generation. Acute side effects, such as increased salivation, increase in heart rate, systemic arterial pressure and intracranial pressure necessitate careful monitoring during intravenous administration of ketamine, even in subanesthetic doses. However, major burden of ketamine administration lies in it\u27s ability to produce psychotomimetic side effects and emergence delirium. Esketamine nasal spray has now been widely approved and is considered safe in terms of acute side effects, tolerability and consistent therapeutic benefit

Impact of intravenous oxytocin on lung haemodynamics and gas exchange during caesarean section under general and spinal anaesthesia

Numerous studies have proven haemodynamic effects of oxytocin, yet there is not much knowledge about the impact of oxytocin on lung haemodynamics and gas exchange. Our goal was to determine the potential impact of intravenous oxytocin on lung haemodynamics and arterial oxygen saturation in patients undergoing Caesarean delivery and to determine the possible difference in arterial oxygen saturation between general and spinal anaesthesia after intravenous administration of oxytocin. Methods. Total of 215 patients scheduled for elective Caesarean delivery were included in the study and randomised into two groups: Caesarean section under spinal anaesthesia and Caesarean section under general anaesthesia. After excluding the patients with severe intraoperative blood loss and those given the standard doses of oxytocin, 70 patients (35 per group) were left for statistical analysis. Patients in both groups were given 10 international units (IU) of oxytocin as a bolus dose plus 10 IU of oxytocin in infusion through 3 minutes, after clamping and cutting of the umbilical cord. Oxygen saturation values throughout the whole procedure were compared between the two groups. Results. Oxygen saturation values decreased more often and to a greater degree in general anaesthesia group than in the spinal anaesthesia group after intravenous administration of oxytocin (all P < 0.05). Conclusion. Drop in arterial oxygen saturation after intravenous oxytocin is inside the safety range among full-term healthy partiurents undergoing spinal or general anaesthesia for Caesarean section. Larger studies on patients with risk factors are needed to conclude the safety of oxytocin in those patients

Vasoactive stress hormone (adrenaline, noradrenaline and cortisol) concentration in plasma after administration of low doses of S-(+)-ketamine epidurally

Background and Purposes: The aim of this study was to investigate the effect of epidurally administered S-(+)-ketamine on vasoactive stress hormones. It was a prospective study conducted after approval of the Ethical Committee and informed consent of patients. Materials and Methods: The study was performed on 80 patients: 40 patients in Group 1 (0.5% bupivacaine) and 40 patients in Group 2 (0.5% bupivacaine + 25 mg S-(+)-ketamine – 0.326 mg/kg-bm). All patients were adults aged between 18 and 45 years, ASA I and II with epidural anaesthesia for a surgical procedure. Vasoactive parameters: concentrations of adrenaline, noradrenaline and cortisol were measured 30 minutes before setting the vein pathway and 17–25 min. after application of anaesthetics. Results: There were no statistically significant changes in vasoactive stress hormones (adrenaline, noradrenaline and cortisol) plasma concentrations after administering 0.5% bupivacaine, 0.5% bupivacaine + S-(+)- -ketamine epidurally. Conclusion: Setting central nervous block before skin incision, using local anaesthetic, and S-(+)-ketamine, leaves concentrations of stress hormones in plasma within referent values. Adding a low dose of S-(+)- -ketamine into the epidural space in combination with 0.5% bupivacaine does not have an effect on the concentration of stress hormones in plasma