[Recognition and treatment of chronic wound infection]. / Prepoznavanje i lijecenje infekcije kronicne rane.

Recognition and treatment of a chronic wound infection is an extraordinarily complex task that requires team work and purposeful and graduate resolving of the problem. Chronic wound infection is the most risky complication because it may have fatal outcome for the patient. The principles of best clinical practice include thorough examination of the patient with respect to endogenous diseases and risk factors, defining the locality of infection and wound characteristics, along with clinical symptoms of infection. Based on the wound status, diagnostic procedures are initiated and the causative agent and its sensitivity to antibiotics determined. With respect to the seriousness of the clinical picture, a plan of surgical interventions is developed. The main procedure is debridement, followed by supportive treatment methods, the choice depending on the indications and contraindications. The targeted method of treatment is systemic administration of antibiotics along with debridement. It is important to know that on approaching a chronic infected wound, the principles of sepsis and antisepsis should be observed. In clinical practice, there is a discrepancy between the adopted criteria for efficient treatment based on the evidence-based practice and objective and subjective problems that obstruct it. Thus, according to statistical data, 50% of antibiotics are prescribed wrongly or are rendered inefficient for some reason. Only half of the patients are treated correctly. It is high time to reach consensus on this issue and accept the facts relevant for the treatment of chronic infected wound, i.e. evidence-based medicine.

[Early carotid endarterectomy in symptomatic patients - our experience]. / Karotidna endarterektomija u simptomatskih bolesnika u ranoj fazi - nasa iskustva.

Carotid endarterectomy is the gold standard as a therapeutic regimen for patients with high grade symptomatic stenosis of the internal carotid artery (ACI). This study analyzed the effect of early carotid endarterectomy in patients undergoing an operative procedure 2-3 weeks after the development of ischemic neurologic symptoms, considering the frequency and type of complications in the postoperative period. Patients included in this study were those with significant symptomatic ACI stenosis (70%-99%), which caused ischemic stroke or transient ischemic attacks (TIA). Patients with ischemic stroke were operated within twenty days of the initial neurologic event, whilst in those with symptoms of TIA, surgery was performed immediately after diagnostic work-up. In all cases, carotid endarterectomy was performed under general anesthesia with the use of protective intraluminal shunt. In the vast majority of cases, tucking or Kunlin's sutures of the distal intima were applied. All procedures were performed between January 2008 and October 2012, and the total number of patients was 69. All patients underwent the same follow up program. Follow up carotid ultrasound was performed routinely on postoperative day 7 and at 1, 3, 6 and 12 months. In this study, 27 (39%) patients suffered minor ipsilateral stroke and 42 (61 %) patients had TIA symptoms with verified significant ACl stenosis. Postoperative complications were observed in four (5.26%) patients. Two (2.63%) patients developed ischemic stroke after the procedure and two (2.63%) patients developed ACI restenosis in the late postoperative period and were treated by endovascular stenting. In conclusion, we found that early carotid endarterectomy was of greater benefit than delayed endarterectomy, which is in keeping with the published studies. The leading observation was that in selected patients, early carotid endarterectomy was not associated with a higher risk of postoperative complications in comparison with delayed endarterectomy and could be performed safely.

[Rare disorders of extracranial carotid arteries]. / Rijetke bolesti ekstrakranijskih karotidnih arterija.

Abnormalities of the internal carotid arteries (ACI) are rare findings, usually not linked with neurologic symptoms and frequently are diagnosed during routine duplex scanning or angiographic examination. These abnormalities are predominantly elongation of the vessel that leads to kinking, coiling or tortuosity of the artery, and the origin is congenital or acquired related to atherosclerosis. We report on two symptomatic cases related to elongation of AC. The first case was a 56-year-old female that had bilateral coiling. The second patient was a 64-year-old female that suffered from symptomatic double coiling of the left ACI connected with high grade stenosis. In both cases, successful operation was done with resection of the elongated and stenosed ACI segment and reanastomosis of the ACI and common carotid artery. Postoperatively, symptoms were resolved. In symptomatic cases of isolated carotid elongations, surgical treatment is a better option than conservative medical treatment alone, whilst in asymptomatic ACI elongation, conservative medical treatment is advised.

Local or spinal anesthesia in acute knee surgery.

The aim of the study was to assess the efficacy, safety and complications of two anesthetic techniques including local and spinal anesthesia. A total of 436 patients received local (LA group = 250) or spinal (SA group = 186) anesthesia during a year period. SA group received 0.5% Bupivacaine 5 mg/mL. LA group received portal injection (5 mL lidocaine 2% with adrenaline) and intra-articular injection into the knee (10 mL lidocaine 2% with adrenaline). The following parameters were assessed: intraoperative pain (10 cm VAS: 0 = no pain, 10 = extreme pain), surgical operating conditions, patient satisfaction score (1 = very satisfied, 4 = very unsatisfied), postoperative analgesia, and time to discharge. In LA group, 97.6% (244/250) of patients experienced no pain throughout the procedure. Only six (2.4%) patients required conversion to general anesthesia. In SA group, two patients required conversion to general anesthesia. In both groups, 93.6% of patients were either satisfied or very satisfied with their anesthesia. The need ofpostoperative analgesics was higher in SA compared with LA group (p = 0.001). The mean postoperative stay was significantly shorter in LA than in SA group (p = 0.001). Ninety-four percent of LA and only 68% of SA patients were discharged from the hospital within 2 hours of the procedure. The rate of complications differed significantly between LA and SA groups (p = 0.037). Outpatient arthroscopy of the knee under local anesthesia is a simple, reliable, and safe alternative to spinal anesthesia, for patients in whom intraarticular disorders requiring diagnostic arthroscopy and arthroscopic surgery.

Evaluation of bacteremia in a pediatric intensive care unit: epidemiology, microbiology, sources sites and risk factors.

Bacteremia is a common cause of morbidity and mortality in children treated in pediatric intensive care unit (PICU). We have investigated the causative agents of bacteremia in our PICU over a one-year period, to determine mortality associated with such infection and identify the dependent predictors for morbidity and mortality. From 1 January till 31 December 2006, 479 patients were admitted in the PICU and 379 blood culture samples were taken. Samples were incubated in the BACTEC 9050 System, and isolates identified by routine microbiological methods. A pair of samples taken for aerobic and anaerobic culture were statistically regarded as one sample. Data collected from the medical records of each patient were recorded onto standardized collections sheets and included demographic information, predisposing conditions, source(s) of infection, important clinical and laboratory parameters at the time of infection, and microbiological data. Based on these data, positive blood cultures were classified as either contaminants or true bacteremias. During a year period, 117 episodes of bacteremia were documented in 72 patients. The most frequent isolates were the coagulase-negative staphylococci 32.2% (39), followed by Candida spp. 30.5% (36). The mean white blood cell count (WBC) on the day of bacteremia was 15.2 x 10(9)/L (range 0.1-48.0 x 10(9)/L), and 3.3% of episodes occurred in neutropenic (WBC count < 1 x 10(9)/L) children. The mean temperature on the day of infection was 38.2 +/- 1.1 degrees C (range, 34-41 degrees C). Some newborns 23% (n = 5) had a significantly lower mean temperature (p < 0.02) and lower mean WBC count (p < 0.05) than older children. Hemodynamic instability was noted in 11% of bacteremic episodes. Among all bacteremias, intravascular catheters were implicated in 22.6%, pneumonia in 20.4%, genitourinary tract in 14.2%, surgical wounds in 11.7% and, gastrointestinal tract in 9.8%. Seven patients died because of sepsis. Early diagnosis, prompt blood culture reports, followed by appropriate antibiotic treatment is essential in reducing mortality in such patients. Short hospital stay and restricted use of invasive devices should be the aims to reduce the risk of bacteremia during the stay in the PICU.