Non-Medical Factors Associated with the Outcome of Treatment of Chronic Non-Malignant Pain: A Cross-Sectional Study.

BACKGROUND: Chronic pain is a global public health issue with increasing prevalence. Chronic pain causes sleep disorder, reactive anxiety, and depression, impairs the quality of life; it burdens the individual and society as a whole. The aim of this study was to examine non-medical factors related to the outcome of the treatment of chronic non-malignant pain. METHODS: A cross-sectional study with two groups of patients was conducted using a questionnaire with biological, psychological, and social characteristics of patients. Since this study was cross-sectional, it was not possible to determine whether some factors were the cause or the consequence of unsuccessful treatment outcome, which is at the same time one of the disadvantages of cross-sectional studies. RESULTS: The poor outcome of the treatment of chronic non-malignant pain in a multivariate binary logistic regression model was statistically significantly associated with the lower quality of life (OR = 0.95 (95% CI: 0.91-0.99; p = 0.009), and higher depression level OR = 1.08 (95% CI: 1.02-1.14; p = 0.009). The outcome of the treatment was not directly related to social support measured by the multivariate binary logistic regression model (OR = 1.04, 95% CI: 0.95-1.15, p = 0.395), but solitary life (without partner) was (OR = 2.16 (95% CI: 1.03-4.53; p = 0.043). CONCLUSION: The typical patient with a poor pain management outcome is retired, presents depressive behavior; their pain disturbs general activity and sleeping. Moreover, they have a physically disturbed quality of life and require self-treatment due to the inaccessibility of doctors and therapies. The principle of treatment of patients with chronic, non-malignant pain should take into account a biopsychosocial approach with individually adjusted procedures.

Effects of Pressure-Controlleda Volume-Controlled Ventilation on Hemodynamic and Respiratory Parameters in Patients During Laparoscopic Cholecystectomy.

Many papers have been published investigating the effects of intraoperative mechanical ventilation on the incidence of intra- and postoperative respiratory complications. The potential advantages of protective pressure over volume-controlled ventilation mode during laparoscopic surgery have yet to be proven. This study included 60 patients aged between 18 and 70 with ASA score 1-3, body mass index (BMI) ≤35 kg/m2, and without prior history of chronic respiratory diseases, who were scheduled for laparoscopic cholecystectomy under general anesthesia. Patients were assigned randomly to protective pressure or volume-controlled mechanical ventilation mode. The initial results showed no significant differences in respiratory and hemodynamic parameters between the groups. Comparison of patients with BMI ≥25 showed significantly lower peak inspiratory pressure (Ppeak) at 15 (18.52 vs. 21.83 cm H2O, p=0.022), 30 (18.73 vs. 21.83 cm H2O, p=0.009) and 45 (18.94 vs. 22.667 cm H2O, p=0.010) minutes after tracheal intubation in the pressure-controlled ventilation (PCV) group. Other measured parameters were of similar characteristics. It is concluded that PCV and volume-controlled ventilation were equally effective in maintaining adequate ventilation, oxygenation and hemodynamic stability in the groups of patients observed. However, comparison of obese patients revealed some advantages of PCV which, given the present pace of change, should be additionally investigated.

PRACTICAL CHRONIC PAIN ASSESSMENT TOOLS IN CLINICAL PRACTICE.

The aim of the study was to show the role of tools in the evaluation of chronic pain (CP) in general practitioner (GP) everyday clinical practice. The study was done by analyzing electronic database of the first visits of 1090 CP patients referred to the Pain Clinic of the Karlovac General Hospital, Karlovac, Croatia, by their GPs. All patient records were analyzed according to the cause of CP, strongest pain a week before the examination, quality of sleep, and the Patients' Global Impression of Change scale. All statistical analyses were done using the IBM SPSS Statistics version 19.0.0.1 (www.spss.com). CP predominantly occurs in older age group. Patients with musculoskeletal pain accounted for the highest percentage (n = 316; 29%), followed by those with neuropathic pain (n = 253; 23.20%) and those with low back pain (n = 225; 20.60%). The mean pain intensity rating scale score was 8.3 ± 1.8 a week before the examination and the mean quality of sleep score was 6.8 ± 1.9. Moderate and severe sleep quality disorder was significantly present in patients over 65 years of age (p = 0.007), patients with musculoskeletal and neuropathic pain, back pain, and those having rated Patients' Global Impression of Change scale as worsening (p = 0.001). The severity of pain and poor quality of sleep are the leading causes of deterioration of the Patients' Global Impression of Change scale in patients suffering from musculoskeletal and neuropathic pain. In order to treat CP comprehensively, it is important for GPs to evaluate the outcomes of clinical treatment using tools for CP assessment.

Influence of intraoperative cerebral oximetry monitoring on neurocognitive function after coronary artery bypass surgery: a randomized, prospective study.

OBJECTIVES: Postoperative cognitive decline is common after cardiac surgery, but it is often unrecognized at the time of hospital discharge. However, it has a great impact on patient's quality of life. Cerebral oximetry with the INVOS (IN Vivo Optical Spectroscopy) system provides the possibility of non-invasive, continuous measurement of regional cerebral oxygen saturation (rSO2), which can improve patients' outcome. The aim of this study was to examine whether cerebral oximetry can decrease the incidence of cognitive decline after coronary artery bypass grafting. METHODS: We have performed a prospective, randomized study with 200 patients enrolled. Patients were divided into INVOS interventional group and CONTROL group without monitoring of cerebral oximetry. A standardized interventional protocol was performed in the INVOS group to maintain rSO2 above 80% of the patient's baseline value or above 50% of the absolute value. Cognitive evaluation was performed in all patients before and 7 days after surgery. Logistic regression was used to reveal predictors of cognitive decline. RESULTS: The incidence of cognitive decline 7 days after surgery was significantly lower (P = 0.002) in the INVOS interventional group (28%) than in the CONTROL group (52%). Intraoperative use of INVOS monitoring was associated with lower incidence of cognitive decline (odds ratio 0.21). In addition, predictors of cognitive decline revealed by multivariate logistic regression were older age, higher EuroSCORE and SAPS II (Simplified Acute Physiology Score) values, lower educational level and persistence of preoperative atrial fibrillation. Patients with prolonged rSO2 desaturation, defined as rSO2 area under the curve (AUC) of more than 150 min% for desaturation below 20% of baseline or AUC of more than 50 min% for desaturation below 50% absolute value, had an increased risk of cognitive decline. CONCLUSION: Postoperative cognitive outcome was significantly better in patients with intraoperative cerebral oximetry monitoring. Prolonged rSO2 desaturation is a predictor of cognitive decline and has to be avoided.

Possible transfusion-related acute lung injury (TRALI) in cardiac surgery patients.

AIM: To determine the incidence of possible transfusion-related acute lung injury (TRALI) and related risk factors in cardiac surgery patients. METHODS: A single-center prospective cohort study was conducted from January 2009 to March 2010 at the Zagreb University Hospital Center, Croatia. Patient-, transfusion-, and surgery-related data were collected. The study included 262 patients who were observed for respiratory worsening including measurements of arterial oxygen saturation (SaO2), fraction of inspired oxygen (FiO2), and partial pressure of arterial oxygen (PaO2). Possible TRALI was defined according to the Toronto Consensus Conference definition broadened for 24-hour post-transfusion. This cohort was divided in two groups. TRALI group included 32 participants with diagnosis of TRALI and the control group included 220 patients with or without respiratory worsening, but with no signs of ALI. RESULTS: Possible TRALI was observed in 32 (12.2%) patients. Compared with the control group, possible TRALI patients had higher American Association of Anesthesiology scores, higher rate of respiratory comorbidity (43.8% vs 15.5%), and required more red blood cells (median 4, range [2.5-6] vs 2 [1-3]), plasma (5 [0-6] vs 0 [0-2]), and platelet units (0 [0-8] vs 0 [0-0]) (P<0.001 all). Risk factors for possible TRALI were total number of transfused blood units (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.10-1.37) and duration of cardiopulmonary bypass (OR 1.08; 95% CI 1.05-1.11). Post-transfusion PaO2/FiO2 ratio was significantly decreased in possible TRALI patients and significantly increased in transfused controls without acute lung injury. CONCLUSION: We observed a higher rate of possible TRALI cases than in other studies on cardiac surgery patients. Serial monitoring of PaO2/FiO2 ratio and detection of its post-transfusion worsening aids in identification of possible TRALI cases.

The relationship between prolonged cerebral oxygen desaturation and postoperative outcome in patients undergoing coronary artery bypass grafting.

58 patients who underwent on-pump coronary artery bypass graft surgery were evaluated for changes in regional cerebral oxygen saturation (rSO2) measured by near infrared spectroscopy (NIRS). If rSO2 during the operation fell to more than 20% under the baseline, standardized interventions were undertaken to maintain rSO2. Despite those interventions, in some cases we observed inability to maintain rSO2 above this threshold. Therefore we divided patients in two subgroups: 1. without prolonged rSO2 desaturation; 2. with prolonged rSO2 desaturation (area under the curve >150 min% for rSO2<20% of baseline and >50 min% for rSO2<50% of absolute value). The data were analyzed to determine whether there were major differences in outcome of these two groups. 18 out of 58 patients (31%) had prolonged rSO2 desaturation during operation. There was significantly higher number of diabetic patients in group with prolonged rSO2 desaturation (p=0.02). Intraoperative data revealed significantly more blood consumption during cardiopulmonary bypass (p=0.007) and the need for inotropes (p=0.04) in desaturation group. Three patients in prolonged desaturation group and no one in another group had stroke, coma or stupor (p=0.03). Logistic regression analysis revealed diabetes mellitus and age as predictors for prolonged rSO2 desaturation. We concluded that prolonged intraoperative rSO2 desaturation is significantly associated with worse neurological outcome in patients - nonresponders to standardized interventions for prevention of rSO2 desaturation.

Application of the procedural consolidation concept to surgical treatment of children with epidermolysis bullosa: a retrospective analysis.

AIM: To assess the efficacy of the procedural consolidation concept (PCC) at reducing the number of sessions of general anesthesia necessary for treating children with epidermolysis bullosa (EB). METHODS: We examined the records of children treated at Children's Hospital of Zagreb between April 1999 and December 2007. Children treated before the introduction of PCC in January 2005 (n=39) and after (n=48) were analyzed in order to determine the effect of PCC on the occurrence of complications, days of hospitalization, and number of hospitalizations. RESULTS: During the study period, 53 patients underwent 220 sessions of general anesthesia for a total of 743 surgical interventions per session. Before the introduction of PCC (n=39 patients, 83 sessions), the median number of interventions per session was 2 (range 1-5), and after the introduction of PCC (n=48 patients, 137 sessions) it was 4 (range 3-7, P<0.001). After the introduction of PCC, the median number of complications per anesthesia session increased from 2 (range 0-10) to 3 (range 0-10) (P=0.027), but the median number of complications per surgical procedure decreased from 1 (range 0-10) to 0.6 (range 0-2.5) (P<0.001). PCC lengthened each anesthesia session from a median of 65 minutes (range 35-655) to 95 minutes (range 50-405), (P<0.001). Total length of hospitalization was similar before (median 1, range 1-4) and after (median 1, range 1-3) introduction of PCC (P=0.169). The number of hospitalization days per procedure was 3 times lower after the introduction of PCC (median 0.3, range 0.2-3) than before (median 1, range 0.75-1.7) (P<0.001). CONCLUSION: PCC should be considered an option in the surgical treatment of children with EB.

Immeasurable levels of serum phosphate--an unidentified cause of respiratory failure in a diabetic patient.

We report a case of immeasurable levels of serum phosphate in a patient with juvenile type Diabetes mellitus and diabetic ketoacidosis who developed respiratory failure. A 27-year-old female with juvenile type insulin-dependent Diabetes mellitus was admitted because of suspected acute mediastinitis and respiratory failure, probably, among other responsible factors, caused and complicated by undetectable levels of serum phosphate. The serum phosphate concentration three days after aggressive treatment was only 0.2 mmol/L. Furthermore, a significant improvement in weakness and lethargy was observed. To the best of our knowledge, this is the first described case of immeasurable levels of serum phosphate. In patients with Diabetes mellitus, serum phosphate concentrations should be routinely checked in order to avoid additional complications.

[Role of anesthesiologist in endovascular management of intracranial aneurysms]. / Uloga anesteziologa pri endovaskularnom pristupu rjesavanja intrakranijskih aneurizmi.

The aim is to give a review of the anesthesiological approach to neuroradiological endovascular treatment of intracranial aneurysm in Croatia since 2004, when the first procedure was done. It took place at University Department of Radiology, Zagreb University Hospital Center. The optimal conduct of anesthesia in the neuroradiology suite requires careful planning of each individual procedure. Essential components are detailed patient evaluation and due understanding of the underlying neuropathology. An open channel of communication between the radiologist and the anesthesiologist is important for routine care but is crucial in case of disasters that may occur during the procedure. In the patient management the basic principles of neuroanesthesia cannot be avoided. This includes optimization of CBF, perfusion pressure, control of intracranial pressure (ICP) and close monitoring of blood pressure (BP), fluid status and body temperature. The choice of anesthetic agents and techniques remains in the hands of the anesthesiologist. The needs of the neuroradiologist and the procedure have to be considered. Most institutions have their protocols and some favor conscious sedation whereas others prefer general anesthesia. There is little evidence in favor of either technique. The better image quality obtained from the motionless patient during digital subtraction angiography favors the use of general anesthesia over any other technique. Since the procedure is becoming very complex, the need for precise BP control and preparation for potential catastrophic complication are considerations for general anesthesia. Aneurysm rupture during endovascular procedures is not common but remains a potential risk. The incidence ranges from 2.3% to 3% and even higher in patients with already ruptured aneurysms. The mortality rate is up to 20% in case of rupture, especially if massive subarachnoid hemorrhage occurs. Anesthesiologic treatment depends on the severity of bleeding and includes maintaining CPP, lowering ICP, reversal of anticoagulation and patient transfer to the neurosurgical operating room if immediate ventriculostomy is needed. During a six month period, 55 patients underwent endovascular treatment of cerebral aneurysm at our hospital. They all were managed under general anesthesia. Since one of the critical roles of the anesthesiologist in the interventional radiology suite is to provide anticoagulation, the protocol of giving clopidogrel was followed, loading dose of 225 mg p. o. to each patient on the day of the procedure and immediately upon introducing microcatheter, heparin iv 70 IU/kg (average of 5000 IU), followed by boluses of 15 IU/kg (approx. 1000 IU) every 60 minutes. Activated clotting time was monitored for the effect of heparin. All patients except four were brought out of anesthesia at the table, immediately after the procedure for their neurological status to be assessed. None of the patients died during the procedure or within the first 24 hours. The mortality was up to 3.6% (two patients died on days 3 and 5 of the procedure). We had only one case of aneurysm rerupture during embolization with Guglielmi detachable coil, followed by cardiac arrest, but the patient (a 32-year-old woman) was resuscitated successfully and underwent standard neurosurgical procedure with full recovery in ICU after 14 days. There were 4 (7.2%) cases of vasospasm followed by ischemia, nimodipine treated, 2 with transient neurological dysfunction and another 2 with permanent hemianopsia. Interventional neuroradiology is rapidly and continually evolving, providing opportunities for the anesthesiologist to be part of this branch of medicine. It is essential to keep up-to-date in the knowledge of neuroanesthesia, neuropathology and interventional neuroradiology. In spite of the relatively non-invasive nature of the procedures, serious, even fatal complications may occur. Therefore, the role of anesthesiologist and his/her cooperation with neuroradiologist is crucial for successful results.

Stairs climbing test with pulse oximetry as predictor of early postoperative complications in functionally impaired patients with lung cancer and elective lung surgery: prospective trial of consecutive series of patients.

AIM: To test the predictive value of stairs climbing test for the development of postoperative complications in lung cancer patients with forced expiratory volume in one second (FEV1)<2 L, selected for an elective lung surgery. METHODS: The prospective study was conducted in 101 consecutive patients with an FEV1<2 L selected for elective lung surgery for lung cancer. Preoperative examination included medical history and physical examination, lung function testing, electrocardiography, laboratory testing, and chest radiography. All patients underwent stairs climbing with pulse oximetry before the operation with the number of steps climbed and the time to complete the test recorded. Oxygen saturation and pulse rate were measured every 20 steps. Data on postoperative complications including oxygen use, prolonged mechanical ventilation, and early postoperative mortality were collected. RESULTS: Eighty-seven of 101 patients (86%) had at least one postoperative complication. The type of surgery was significantly associated with postoperative complications (25.5% patients with lobectomy had no early postoperative complications), while age, gender, smoking status, postoperative oxygenation, and artificial ventilation were not. There were more postoperative complications in more extensive and serious types of surgery (P<0.001). The stairs climbing test produced a significant decrease in oxygen saturation (-1%) and increase in pulse rate (by 10/min) for every 20 steps climbed. The stairs climbing test was predictive for postoperative complications only in lobectomy group, with the best predictive parameter being the quotient of oxygen saturation after 40 steps and test duration (positive likelihood ratio [LR], 2.4; 95% confidence interval [CI], 1.71-3.38; negative LR, 0.53; 95% CI, 0.38-0.76). In patients with other types of surgery the only significant predictive parameter for incident severe postoperative complications was the number of days on artificial ventilation (P=0.006). CONCLUSION: Stairs climbing test should be done in routine clinical practice as a standard test for risk assessment and prediction of the development of postoperative complications in lung cancer patients selected for elective surgery (lobectomy). Comparative to spirometry, it detects serious disorders in oxygen transport that are a baseline for a later development of cardiopulmonary postoperative complications and mortality in this subgroup of patients.

Health related quality of life following cardiac surgery--correlation with EuroSCORE.

OBJECTIVE: To explore differences in the health-related quality of life (HRQOL) of patients before and after cardiac surgery, to compare the results with norms of Croatian population and to correlate the results with values of EuroSCORE. METHODS: This was a prospective observational study with repeated measurements using the Short Form SF-36 health survey before surgery and 1 year after discharge, to assess changes in quality of life. RESULTS: A total number of 111 patients were included in the study. Seventy-one patients (64%) responded to second measurement of HRQOL 1 year after surgery. The mean age was 61 years, patients were predominantly male and the majority of patients were admitted for coronary artery bypass graft. The prevalence of comorbidity was relatively high. Preoperative mean values of study population were statistically lower than those representing Croatian general population in five out of eight health domains: physical functioning (p<0.001), role physical (p<0.001), bodily pain (p<0.001), social functioning (p<0.001) and mental health (p<0.001). Data show significant improvement 1 year after discharge in four out of eight health domains: physical functioning (p=0.02), role physical (p<0.001), social functioning (p=0.004) and mental health (p=0.03). A subgroup of 30 patients with EuroSCORE > or =6 shows postdischarge improvements in the majority of scales: role physical (p<0.001), bodily pain (p<0.001), vitality (p=0.03), social functioning (p=0.01), role emotional (p=0.03) and mental health (p=0.002), and group with EuroSCORE <6 shows postdischarge improvement only in one health domain - role physical (p<0.001). CONCLUSIONS: The health status of patients one year after hospital discharge shows a statistically significant improvement in half of the domains of physical and mental health compared with presurgery status. The high-risk group of patients (EuroSCORE > or =6) were likely to have significant improvement in greater number of health domains following surgery than the low- and medium-risk group (EuroSCORE <6).

Chronic obstructive pulmonary disease and weaning of difficult-to-wean patients from mechanical ventilation: randomized prospective study.

AIM: To compare T-tube and pressure support ventilation (PSV) as two methods of mechanical ventilation weaning of patients with chronic obstructive pulmonary disease (COPD) after failed extubation. METHODS: A prospective randomized trial carried out at the multidisciplinary intensive care unit (ICU) over 2 years included 136 patients with COPD who required mechanical ventilation longer than 24 hours. The patients who could be weaned from mechanical ventilation were randomized to either a T-tube or PSV 2-hour spontaneous breathing trial. The patients in whom 2-hour trial was successful were extubated and excluded from further research. Patients in whom 2-hour trial failed had mechanical ventilation reinstated and underwent the same weaning procedure after 24 hours in case they fulfilled the weaning criteria. The weaning outcome was assessed according to the following parameters: extubation success, mechanical ventilation duration, time spent in ICU, reintubation rate, and mortality rate. RESULTS: Two-hour trial failed in 31 patients in T-tube and 32 patients in PSV group, of whom 17 and 23, respectively, were successfully extubated (P<0.001, chi(2)test). Mechanical ventilation lasted significantly longer in T-tube than in PSV group (187 hours vs 163 hours, respectively, P<0.001, Mann-Whitney test). Also, patients in T-tube group spent significantly more time in ICU than patients in PVS group (241 hours [interquartile range 211-268] vs 210 hours [211-268], respectively, P<0.001, Mann-Whitney test). Reintubation was required in 8 and 6 patients in T-tube and PVS group, respectively, and death occurred in 4 and 2 patients, respectively, during ICU stay. CONCLUSION: Patients with COPD who failed the 2-hour spontaneous breathing trial had more favorable outcome when PVS rather than T-tube method was used for weaning from mechanical ventilation.

[Fast track surgery--enhanced multimodal rehabilitation after surgery]. / "Fast track" kirurgija--ubrzana multimodalna rehabilitacija kirurskih bolesnika.

Despite constant improvements in surgical technique and perioperative care which led to significant reductions in mortality and morbidity after general surgery, complication rates after major abdominal surgery still reach 15-40%. The main cause of postoperative complications (not linked to surgical technique itself) is the perioperative stress reaction potentiated by pain, inadequate perioperative fluid management, immobilisation and hypothermia. Multimodal rehabilitation of surgical patients represents the practical application of advances in surgery, anaesthesiology and postoperative rehabilitation with the aim of reducing perioperative stressors and facilitating an early return of the patient to his/her preoperative functional status. Besides discussing various aspects of multimodal rehabilitation, the authors present their own first experiences with its introduction into everyday clinical practice.

Analysis of preincisional and postincisional treatment with alpha2-adrenoreceptor agonist clonidine regarding analgesic consumption and hemodynamic stability in surgical patients.

Preemptive analgesia aims to prevent the sensitization of central nervous system, hence the development of pathologic pain after tissular injury. The aim of the study was to assess the effect of preincisional clonidine treatment on analgesic consumption and hemodynamic stability compared to clonidine administered at the end of the operation and control group. Ninety-one patients undergoing elective colorectal surgery were randomly assigned to four groups: peroral clonidine before operation, epidural clonidine before operation, epidural clonidine at the end of operation, and epidural saline before operation as a control group. After the operation, patient-controlled analgesia with epidural morphine was instituted. Analgesic consumption, blood pressure and heart rate were obtained at 1, 2, 6 and 24 h postoperatively, and the cumulative consumption of analgesics was assessed at the end of the study period. Significant differences (p < 0.05) in postoperative systolic blood pressure, with highest hemodynamic stability was observed at 1 h and 6 h in the group of patients administered epidural clonidine before operation. In this group of patients we found significant reduction in analgesic consumption during the study period (p < 0.05), compared to other groups. The cumulative consumption of analgesics assessed at the end of the study period was significantly reduced (p < 0.05) in the group of patients administered epidural clonidine before operation (8.40 +/- 3.74, respectively) as compared with the peroral clonidine before operation (16.79 +/- 5.75, respectively), epidural clonidine at the end of the operation (11.11 +/- 4.24, respectively) and control group of patients (18.00 +/- 6.45, respectively). Preincisional administration of epidural clonidine was associated with a significantly lower analgesic use, lower cumulative analgesic consumption and greater hemodynamic stability, in comparison with other groups.

[Anesthesia and perioperative management of patients with resection for esophageal carcinoma]. / Anestezija i perioperacijski postupak u resekcijskoj kirurgiji karcinoma jednjaka.

The current approach to the anesthetic procedure and postoperative intensive therapy after esophageal resection for esophageal carcinoma, as well as characteristic perioperative pathophysiological events are presented. The contributory factors of severe postsurgical morbidity are considered too. Esophagectomy is an extented procedure which includes laparotomy, thoracotomy and often cervicotomy, and carries a great surgical stress with a huge fluid shift. It is mostly performed in the aged population with a certain co-morbidity: malnutrition, compromized immune status, respiratory and cardiovascular diseases. Standardization of esophageal resection and reconstructive techniques together with the optimal perioperative management significantly reduce operative mortality. Preoperatively, the patients' nutritive, respiratory and cardiac status should be improved. Intraoperatively, beside adequate depth of anesthesia which enables the optimal metabolic response to surgical stress, the invasive hemodynamic monitoring with insertion of pulmonary artery catheter is of great importance. The aim is to ensure adequate tissue perfusion and oxygenation avoiding pulmonary overhydration at the same time. Postoperatively, important role has epidural analgesia, allowing proper breathing and coughing and routine usage of fiberbronchoscopy for clearance of pulmonary secretion. After resection there are several conditions which contribute to cough and swallow disturbances: bilateral vagotomy, the absence of upper and lower esophageal sphincters, transient aperistalsis of the substitute, sometimes a transient vocal cord paresis. All of these make patients prone to regurgitation and aspiration of duodenal and gastric juice. Currently, the pulmonary complications are the leading problems after this procedure, so their prevention and early treatment are the key tasks for the clinicians.

[Role of transthoracic echocardiography in evaluation of cardiac risk in thoracic surgery]. / Uloga transtorakalne ehokardiografije u procjeni kardijalnog rizika u torakokirurskog bolesnika.

BACKGROUND AND OBJECTIVE: It is not precisely defined which group of non-cardiac surgery patients should undergo transthoracic echocardiography in preoperative preparation. This study was prospectively performed to find out whether the routine use of echocardiography is justified in patients scheduled for lung resection, and to assess its role in cardiac risk evaluation. METHODS: Patients classified as ASA III who were identified as having minor or intermediate predictors of cardiac risk were included in the study. Based on this triage, 130 patients underwent transthoracic echocardiography. RESULTS: Intermediate index of increased perioperative cardiovascular risk was recorded in 36.2% and low index in 63.8% of patients. Preoperative anesthesiologic examination revealed some form of cardiac arrhythmia in 28.5%, symptoms of coronary disease in 25.4%; hypertension in 52.3%, and chronic obstructive pulmonary disease in 16.9% of patients. Transthoracic echocardiography showed the ejection fraction of 60% in 86.9% and of 40%-49% in only one patient. Left ventricular contractility was preserved in 96.2% of patients. Diastolic relaxation was weakened in 42.3% of patients. Mild mitral insufficiency was found in 29.2%; aortic stenosis in 1.5%, mild aortic insufficiency in 2.3%, mild pulmonary hypertension in 70.8%, and severe pulmonary hypertension in only 1.5% of patients. Pulmonectomy was performed in 26.9%, lobectomy in 62.3% and segmental tumor resection in 10.8% of patients. Only 26.2% of patients had peri- and postoperative complications: tachyarrhythmia and atrial fibrillation with rapid ventricular answer in 16.2%, hypotension 1.5%; hypertension in 2.3% and hypertension and arrhythmia in 1.5% of patients. Three (2.3%) patients died. None of our patients had Goldman's score higher than 25; according to Detsky index our patients belonged to 0-15 point group, class I, with the foreseen risk %. CONCLUSIONS: Transthoracic echocardiography is not justified in the routine preoperative preparation of thoracosurgical patients classified as ASA III with clinically minor and intermediate indexes of increased cardiovascular risk. It should be done in selected patients, primarily those that have history data and clinical picture consistent with major indices of an increased cardiovascular risk.

Comparison of pressure support and T-tube weaning from mechanical ventilation: randomized prospective study.

AIM: To compare T-tube and pressure support ventilation (PSV) as two methods of weaning patients from mechanical ventilation. METHODS: A randomized prospective study included 260 patients who received mechanical ventilation for more than 48 h, and who were admitted to the intensive care unit (ICU) at Dr. Josip Bencevic General Hospital in Slavonski Brod, between August 1999 and October 2000. After fulfilling the clinical criteria for weaning, the patients were randomly assigned to a 2-h trial of spontaneous breathing either with a T-tube system (n=110) or PSV of 8 cm H2O (n=150). The patients who fulfilled weaning criteria at the end of the 2-h trial were extubated. If any signs of poor procedure tolerance were observed during the 2-h trial, the mechanical ventilation was reinstituted. In such patients, the same weaning procedure was repeated after 24 h, or when the patient's clinical condition permitted. Two methods of weaning were compared according to the patient's clinical characteristics, objective parameters, and procedure outcome. RESULTS: Eighty (73%) patients in the T-tube group and 120 (80%) patients in PSV group successfully completed the 2-h trial and were extubated. Thirty patients in the T-tube group and 30 in the PSV group had weaning difficulties. Total length of additional mechanical ventilation and total length of stay at ICU were significantly shorter in patients undergoing PSV weaning (p<0.001 for all, Man-Whitney test). For the patients with weaning difficulties and Acute Physiology and Chronic Health Evaluation (APACHE) II score >20 on admission, PSV was the superior method of weaning according to rate of successful extubation, time of weaning from mechanical ventilation, total time of mechanical ventilation, and length of ICU stay (p<0.001 for all, Man-Whitney test). CONCLUSION: In patients with weaning difficulties, PSV with 8 cm H(2)O was more successful weaning method than T-tube.

Hyperbaric oxygenation combined with streptokinase for treatment of arterial thromboembolism of the lower leg.

Thromboembolic occlusion of peripheral arteries is a common problem in patients referred to vascular surgery departments. Standard treatments include catheter aspiration techniques, use of fibrinolytic agents and surgical thrombendarterectomy. Recent reports have described the use of hyperbaric oxygen therapy in patients with limb ischemia, yet their main focus has been on patients with chronic disorders. We present the case of a 74-year-old woman with atrial fibrillation and acute thromboembolic occlusion of the posterior tibial artery. The patient presented with severe pain in the right calf, unresponsive to non-opioid parenteral analgesia and accompanied by coldness, numbness and partial motor palsy of the right foot. After 60 minutes of oxygenation in a hyperbaric chamber with a pressure of 2.2 bar, the pain receded, although without signs of restored blood flow in the occluded artery. After fibrinolytic therapy with streptokinase, patency of the posterior tibial artery was verified by return of palpable pulsations and color Doppler ultrasonography. By combining hyperbaric oxygenation and streptokinase in the treatment of lower-leg arterial thromboembolism we achieved regression of ischemic pain, prolongation of the survival time of tissues compromised by ischemia and resolved the cause of the ischemia. We believe the use of this therapeutic strategy in selected cases of peripheral arterial thromboembolism is justified.