Preoperative femoral vein velocity in maximal flexion is a predictor of deep vein thrombosis in patients undergoing total hip arthroplasty.

The aim of the study was to investigate if preoperative blood flow velocity in femoral vein in different positions of the hip during total hip arthroplasty (THA) is a predictor of postoperative deep vein thrombosis (DVT). In patients undergoing THA, blood flow velocity and diameter of proximal femoral vein on THA side were measured preoperatively in four flexion positions of the hip. After THA, patients were followed up for 42 days for DVT occurrence, and clinical features of patients with and without postoperative DVT were compared. The mean blood flow velocity in maximal flexion (90º+) preoperatively was significantly lower in patients with postoperative DVT (19/103) compared to patients without it (8.4±2 cm/s vs. 10.6±2.3 cm/s; p<0.001). Using the receiver operating characteristic curve analysis, the cut-off value for blood flow velocity during maximal flexion was 8.24 cm/s. In addition, anesthesia duration, duration of surgical position of the patient, body mass index, amount of blood transfused after surgery, and clinical signs of DVT were markedly different between patients with and those without postoperative DVT. Blood flow velocity in femoral vein in maximal flexion of the hip (90º+) measured prior to THA is an independent predictor of postoperative DVT.

A Difference in Bleeding and Use of Blood and Blood Products in Patients who Were Preoperatively on Aspirin or Dual Antiplatelet Therapy Before Coronary Artery Bypass Grafting.

BACKGROUND: Postoperative bleeding in patients who underwent elective coronary artery bypass surgery (CABG) may increase due to preoperative anticoagulant therapy indicative of their disease - acute coronary syndrome or implanted coronary artery stent. Increased bleeding in many cases requires the use of blood and blood derivatives, and sometimes even reoperation. Their use poses the risk of complications, may extend the hospitalization. METHODS: Our observation retrospective study included 131 patients, 41 treated with aspirin and 90 treated with aspirin and clopidogrel. All underwent for the first time elective on-pump isolated CABG surgery at Clinic for cardiovascular surgery of Clinical Center University of Sarajevo, in period June 2016 to September 2017. The data were collected from patient's records. RESULTS: Out of 131 patients,73.3% were male. The average age was 62. The average total drainage during the first 48 postoperative hours in ASA group was 1027.4±404.9ml and 1049.8±371.3ml in DAPT group. The mean number of whole blood transfusions in the DAPT group washigher compared to ASAgroup. The average number of fresh frozen plasma were higher in the DAPT group 0.84±0.51 compared to the group ASA 0.39±0.07, as well the average thrombocytes transfusions were slightly higher in the DAPT group. Statistical analysis suggests that there is no significant difference between the observed groups (p>0.05). Also, our study did not show a statistically significant difference between arrhythmia onset, the length of mechanical ventilation, use of protamineand tranexamic acid. Reoperation due to postoperative bleeding was recorded in 2 cases in the DAPT group as well as 2 lethal cases. CONCLUSION: In our study, we could not demonstrate less postoperative bleeding and use of blood and blood products in a group of patients who were preoperatively treated with aspirin compared to patients with dual antiplatelet therapy in the elective isolated CABG surgery.

Improvement of ejection fraction after coronary artery bypass grafting surgery in patients with impaired left ventricular function.

OBJECTIVES: The present study evaluates our experience with aorto-coronary bypass grafting in patients with severe dysfunction of left ventricle (LV) and low ejection fraction-EF(<35%). Revascularization of myocardium in this settings remains contraversial because of concerns over morbidity, mortality and quality of life. MATERIAL AND METHODES: Forty patients with severe coronary artery disease and dysfunction of LV (low ejection fraction <35%) underwent coronary artery bypass grafting in period of 3 years. Preoperative diagnostic of 40 patients was consisted of anamnesis, clinical exam, non-invasive methods EHO, MR and invasive diagnostic methods-cateterization. The major indication for surgery was severe anginal pain, heart failure symptoms and low ejection fraction. Internal mammary artery was used in all operated patients. RESULTS: Average age of patients who have been operated was 59,8. In the present study, 81,3% were male and 18,8% female. We found one-vessel disease present in 2,5% (1/40) of patients, two -vessel disease in 40% (16/40), three-vessel disease in 42,5% (17/40) and four -vessel disease in 15% (6/40) of patients. One bypass grafting we implanted in 2,5% patients, two bypasses in 42,5%, three bypasses in 45 5%, and four bypasses in 10% of patients. Left ventricular ejection fraction assessed preoperativly was 18%-27% and postoperatively was improved to 31, 08% in period of 30 days. CONCLUSION: In patients with left ventricular dysfunction, coronary artery bypass grafting can be performed safely with improvement in quality of life and in left ventricular ejection fraction.

Glucosa-Insulin-Potassium (GIK) solution used with diabetic patients provides better recovery after coronary bypass operations.

INTRODUCTION: Tight blood glucose control has become a therapeutical goal for anesthetic management for patients scheduled for cardiac surgery, especially if they are diabetic patients. AIM: This study was created to confirm the benefits of intraoperative GIK solution usage during coronary bypass operation of diabetic patients. METHODS: Patients with type 1 and 2 diabetes mellitus (DM) referred for coronary artery bypass grafting (CABG) were randomized to receive GIK solution (GIK--study group) in the first 24 hours intraoperatively or to receive official Clinical protocol without GIK solution (non GIK - control group). The primary clinical outcome was the cardiac index (CI) since it represents the most sensitive measure of cardiac work in the immediate postoperative period, and the secondary clinical outcomes were the glycemic control, insulin consumption, duration of mechanical ventilation (MV), potassium level and atrial fibrillation (AF) appearance. RESULTS: One hundred diabetic patients, divided into two groups, were included in the study. The cardiac index did not show a significant difference, although the study group had CI with only minor variations than those of the controlled group, hence the reason we considered the study group as the more stable. The atrial fibrillation showed a difference between two groups, with 14 (28%) patients with postoperative AF in the control group compared with 3 (6%) patients with postoperative AF in the study group. As potassium values were stable in study group, we concluded that it can be one of the reasons for less postoperative AF in this group. The duration of MV showed a significant difference (0,003) between the two groups as well. In the study group the average MV time was 534,38 minutes, compared with the control group with 749,20 minutes. The average value of glucose was 11.1 mmol/l in the control group vs. 9.8 mmol/l in the study group. The study group had less insulin consumption in order to maintain target glycemia (p = 0.001). In the non GIK group average insulin consumption was 44 IJ per patient vs. 28.5 IJ in the GIK group. CONCLUSION: Intraoperative GIK solution given to diabetic patients with CABG operation provides more stable CI, shorter time of MV, more stable values of potassium which provides normal rhythm and less AF onset, less insulin to maintain target glycemia. All the above mentioned provides more stable intraoperative hemodynamic and better recovery of diabetic

Minimally invasive mini-thoracotomy access as a surgical method in state-of-the-art treatment of single-vessel coronary heart disease.

Aim To compare outcomes of two different surgical techniques of coronary artery bypass grafting (CABG) for treating isolated left anterior descending (LAD) coronary artery disease by full median sternotomy technique vs. minimally invasive approach via left anterior mini-thoracotomy. Methods This retrospective, observational study, which included 61 elective patients, was conducted at the Clinic for Cardiovascular Surgery of the Clinical Centre of the University of Sarajevo in the period from June 2019 to January 2022. Patients were divided in two groups according to the operative technique used, the sternotomy CABG group of 30 patients where the access considered full median sternotomy, and the minimally invasive CABG group where left anterior mini-thoracotomy was performed. The groups were compared by previously defined primary and secondary clinical postoperative outcomes. Results Out of 61 patients, the majority was males, 50 (82%). The analysis of the outcomes of the minimally invasive CABG surgery showed significantly shorter operative times (p=0.001), less postoperative drainage (p=0.001) and transfusion requirements, shorter mechanical ventilation duration (p=0.0001), low major adverse cardiac and cerebrovascular events rates, as well as shorter Intensive Care Unit stay days with mean of 3.3±1.442 days (p=0.025), but no total hospital stay days with mean of 6.7±1.832 days (p=0.075) compared to sternotomy CABG group. Conclusion Minimally invasive approach for CABG surgery in treating isolated single vessel LAD disease, together with the fasttrack protocol, offers a reasonable alternative to full median sternotomy, leading to faster patients' overall recovery and improving the quality of life.

Minimally invasive coronary artery bypass (MICS CABG) in Bosnia and Herzegovina: a single centre, single surgeon cohort experience.

Aim This is the first research in Bosnia and Herzegovina presenting minimally invasive coronary artery bypass grafting surgery (MICS CABG) experience, advantages, and outcomes as compared to conventional surgery (OPEN CABG). Methods This retrospective cross-sectional study was conducted between January 2019 and November 2022 and included patients with indication for surgical revascularization. Results Among 237 patients, males predominated, 182 (76.7%), with a mean body mass index (BMI) of 28.4±3.9, median The Society of Thoracic Surgery Risk (STS) score of 1.55 (0.8, 4.0), short term STS score of 11.2 (6.8, 23.7), mean age of 64.8±8.7 (ranging 41-83) years, 122 (51.4%) underwent OPEN CABG and 115 (48.6%) MICS CABG. MICS CABG took less time (p<0.001; OPEN 3.5±0.8h; MICS 2.8±0.8h) and needed less mechanical ventilation (p<0.001, OPEN 17.3±11.9h; MICS 13.0±12.5h) than OPEN CABG. Even though there was no difference in hospitalization length between groups (OPEN (7.5±3.2), MICS (7.1±4.0)), patients receiving MICS (2.9±1.5) spent less time in the ICU (p=0.0013) than OPEN CABG (3.6±2.8). OPEN CABG used also more blood derivatives, red blood cells (OPEN 292 vs MICS 55), plasma (OPEN 270 vs MICS 86) and platelets (OPEN 71 vs MICS 28). Conclusion Patients undergoing MICS CABG in Bosnia and Herzegovina had less mechanical ventilation hours and less ICU duration compared to OPEN CABG even though the hospitalization duration was very similar. MICS CABG takes less time to be conducted, has fewer CPRs postoperatively, uses less blood derivatives including red blood cells, plasma and platelets.

Off pump Versus On pump Coronary Artery Bypass Grafting: Short-term Outcomes.

Background: Coronary artery disease (CAD) is a major public health issue and a leading cause of death globally. It is one of the most common indications for surgical intervention. There are a lot of different techniques, including CABG, which consists of two approaches: sternotomy and mini-thoracotomy. Different techniques have been developed to improve surgical outcomes, including the use of machine for extracorporal circulation (on-pump) or without it (off-pump). Objective: The objective of this study was to assess whether off-pump CABG offers superior short-term outcomes compared to traditional on-pump CABG in patients undergoing isolated CABG.. Methods: In period between 2022 - 2023, we performed CABG operation in 80 patients. CABG was performed either on- pump or off-pump. Results: The results have shown advantages and disadvantages of one or another type of CABG. We were comparing the duration of surgical procedure, time on mechanical ventilation, drainage volume, neurological incidents, time to discharge, indication for repeat revascularization and mortality between two groups. Conclusion: The choice of surgical technique should be based on individual patient factors, including comorbidities and surgical risks. It is important to say that OPCABG is more challenging than ONCABG, and it is very important that OPCABG is done by skilled, experienced and confident surgeon, which contributes to better outcome and survival.

How Important Impact of Low Level of Hematocrit Can Be on Outcome in Patients Undergoing Off Pump Coronary Artery Bypass Surgery?

Background: Cardiosurgical patients can be often anemic, and preoperative anaemia is associated with increased postoperative complications, as well as morbidity and mortality. Objective: The present study was conducted aiming to determine the influence of lower preoperative hematocrit values on the early postoperative recovery of patients undergoing elective off-pump coronary artery bypass grafting (OPCABG). Methods: Our retrospective study included 150 patients who underwent elective OPCABG surgery from September 2021 to December 2022 at the Clinic for Cardiovascular Surgery University of Sarajevo. Patients were divided into two groups, anemic and non-anemic, with anemia defined as hemoglobin level <130g/l males and <120g/l females. Study observed comorbidities and early postoperative data. Results: Overall prevalence of anemia in OPCABG patients was 36,6%, more frequent among older patients. Comorbidities as chronic obstructive pulmonary disease, hypertension, ejection fraction was quite similar in both groups, but body mass index was significantly higher in the group of patients with anemia (29.9% vs 28.4%). In early recovery period, vasopressors were more used in patients with anemia (63.6% vs 42.1%) and their doses were higher. Total drainage was higher in patients with anemia (744.45±45.72 ml vs 681.58±349.06 ml). Number of transfusions was higher in the group of patients with anemia: red blood cells (0.89±1.29 vs 0.29±0.84; p<0,05), fresh frozen plasma (0.65±1.13 vs 0.41±1.15; p<0,05) and platelets (0.11±0.57 vs 0,07±0.42; p>0,05). Duration of mechanical ventilation was longer in patients with anemia compared to non-anemic patients (623-91±259.83 minutes vs 469±191.13 minutes). Atrial fibrillation occurred more often in patients with anemia (12.7 vs 7.4%). Length of stay in the intensive care unit was without significant difference. Conclusion: Based on our findings, patients who underwent elective OPCABG with lower than normal hematocrit, needed more blood and blood products, more vasopressor drugs in higher doses, longer mechanical ventilation, all which can prolong the patient's recovery and increase the cost of treatment.

Psychosocial influence of COVID-19 on healthcare workers.

Aim To assess a psychosocial impact of the Coronavirus disease 2019 (COVID-19) on health care workers and to quantify the size of depression symptoms, anxiety and stress levels. Methods This cross-sectional study used an anonymous online survey questionnaire as a research instrument and it included 114 health workers of all profiles from the Sarajevo Canton employed in private and public institutions. The research was voluntary, non-commercial and all participants provided an oral informed consent. Depression, Anxiety and Stress Scale (DASS-21) questionnaire was used for assessing emotional status of depression, anxiety and stress. Results The mean age of participants was 40.5±8.44 years with male:female ratio of 0.28. Prevalence of depression was 46.5%, anxiety61.4%, and 36.9% stress. Age and gender had no effect on emotional status, but it was revealed that women achieved higher depression, anxiety and stress scores than men (without statistical significance). The most notable effect on the emotional state was found for direct or indirect contact with COVID-19 patients. Medical workers in direct contact with COVID-19 patients achieved greater depression (p=0.005), anxiety (p=0.001), stress (p=0.030) and total DASS-21 (p=0.003) scores. Conclusion High prevalence of health workers affected by various psychological ailments during the COVID-19 pandemic was found. This evidence underscores the need to address adverse effects of the pandemic on mental health of health care workers.

Deep Sternal Wound Infection After Open-heart Cardiac Surgery and Vacuum-Assisted Closure Therapy: a Single-center Study.

Background: Despite many advances in the prevention, of sternal wound infection, especially deep ones, cardiac surgery with median sternotomy, still presents a significant postoperative complication. Numerous operative and non-operative procedures should be used in treatment, there is a prolonged hospital stay and increased hospital costs treating this postoperative complication. Objective: The present study was conducted aiming to determine the incidences, and risk factors, identify microbiology findings, and antibiotic therapy among patients with DSWI who underwent cardiac surgery with median sternotomy at our Clinic and VAC treatment. Methods: This retrospective observational study was conducted in Clinic for Cardiovascular Surgery at University Clinical Center Sarajevo from November 2015 to November 2020. The data were obtained from 15 patients with deep sternal wound infection (DSWI) following open-heart surgery. The inclusion criteria were DSWI after cardiac operation via median sternotomy, and complete results of microbiological findings obtained by sternal swab. The exclusion criteria were patients with incomplete clinical data. Results: We found that 9 (60%) patients were males and 6 (40%) were females. Coronary artery bypass grafting (CABG) operation had 11 (73,3%) patients, CABG with aortic valve replacement 2 (13,3%), valve replacement surgery operations (13,3%). The average age was 66 years. All patients were elective surgery patients. STS score in the Non-VAC group was 22.6, in the VAC group 16.6, and the average was 14.9. The number of patients with DSWI represents 1% of all sternotomy patients in the observed period. Two risk factors for DSWI had 37% of patients, 25% of them were diabetic, and 3 (9%) were overweight. Enterococcus faecalis was isolated predominantly in 6 (27%) patients, followed by Klebsiella pneumonia 3 (13%), Proteus mirabilis 2 (9%), and Serratia Maecenas 2 (9%). The mortality rate was 33.3% (5 of 15). Conclusion: The results of our study present our experience with DSWI treatment after open-heart surgery. What comes from our experience so far, is that is very important to determine patients who are at risk of developing DSWI after cardiac surgeries to lower its incidence.

Left Ventricular Free Wall Rupture After Acute Myocardial Reinfarction Due to In-Stent Thrombosis in COVID-19 Patient.

Background: Acute left ventricular free wall rupture (LVFWR) is a life-threatening complication of myocardial infarction that requires urgent intervention. Surgical repair has continued to be the treatment of choice. Studies suggest a posterolateral or inferior infarction is more likely to result in free wall rupture than an anterior infarction. LVFWR generally results in death within minutes of the onset of recurrent chest pain, and on average was associated with a median survival time of 8 hours. Prompt diagnosis and management can lead to successful treatment for LVFWR. Objective: The aim of this article was to present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Case report: We present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Although dual antiplatelet therapy introduction and good outcome of PCI were achieved, soon after instant thrombosis of both stents appear to result in transmural necrosis and LVFWR. Urgent catheterization was performed and diagnosed in-stent thrombosis where the ventriculography confirmed LVFWR of the posteroinferior wall. Urgent surgery was performed. Transmural necrosis was noticed alongside the incision line. The incision is sawn with 4 U-stitches (Prolen 2.0 with Teflon buttressed stitches). Another layer of fixation was made by Prolen 2.0 running stitches reinforced with Teflon felts from both sides. A large PTFE patch was fixed to epicardium over the suture line by Prolen 6.0 running stitch and BioGlue was injected in-between patch and LV (Figures 8 and 9). After aortic cross-clamp removal, the sinus rhythm was restored. Conclusion: Despite the high mortality, the urgency and the complexity of surgical treatment the early diagnosis plays a key role in the management of postinfarction LVFWR patients presenting a case of preserved postoperative left ventricular function and accomplished good functional status, as presented in our case.

Our Experiences in the Treatment of Anterior Chest Wall Infections (2015 - 2021).

Background: Sternotomy is a classical surgical procedure for approaching the heart and mediastinum. Sternotomy wound infections can be superficial or deep. Objective: The aim of this study is to retrospectively evaluate the results of two treatments for deep sternal wound infection (DSWI), closed treatment (debridement, refixation and retrosternal irrigation) and open treatment (debridement, VAC therapy and then pectoral flap). Methods: Retrospective analysis of two methods of treatment of DSWI in the period of six years. The first group (G1): surgical debridement, sternum fixation with, if necessary, retrosternal irrigation. The second group (G2): surgical debridement, open sternum with VAC therapy and subsequent pectoral flap with sternum refixation if necessary. Sternotomy wound infection will be classified according to the depth of the affected areas and the time of infection. Risk factors, outcome, local findings, number of revisions, number of hospital treatment days, types of isolates, etiology of sternotomy, time from onset of sternal instability to first surgical treatment will be observed. Results: The number of patients with DSWI was 16, which represents 1% of all sternotomy in the observed period. Mortality in the DSWI group was 35%. Surgical myocardial revascularization was initially performed in 73% of patients with DSWI. Two risk factors for DSWI were in 32% of patients and 25% had diabetes mellitus. The average time for DSWI development in G1 was 10 days (min 0, max 30) and in G2 was 20 days (min 12, max 30). Number of revisions in G1 (min 1, max 2), G2 (min 1, max 3). Average number of hospital days were in G1 23.50 days (SD 13.15), and in G2 38.17 days (SD 28.65). The sternum was osteomyelitic and fragmented in 20% of patients. More than one revision occurred in 40% of patients. The main initial isolate was Enterococcus faecalis in 27% of all DSWI (dominantly in G1 2/3 of all). Conclusion: We found that there is no statistically significant difference in observed treatments, and that each treatment has its own indications. We suggested that studies with a larger sample are needed for a definite opinion on this issue.

Non Invasive Detection of Coronary Sinus Flow Changes Over Time After CABG.

Background: Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization. Objective: Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE). Methods: Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, ß = 0,01 (power = 1-ß ß= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS. Results: Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day. Discussion: Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses. Conclusion: There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Atrial fibrillation and coronary bypass surgery - what can be risk factors for its' appearance?

The main goal of our study was to evaluate possible perioperative risk factors for occurrence of atrial fibrillation in the postoperative period in patients after CABG operations. The study included 140 patients after CABG, divided into two groups - Group I - 64 patients with new onset of POAF and Group II - 76 patients without postoperative atrial fibrillation occurrence. In both groups possible risk factors for atrial fibrillation onset (preoperative and postoperative) were analyzed.Results showed that we can predict new onset of atrial fibrillation after CABG if the following preoperative factors are present - low ejection fraction (less than 40%), LAd > 40mm, higher body mass index (BMI over 30), presence of COPD and older age. Important perioperative factors for onset of atrial fibrillation in our study were longer extracorporeal circulation, increased dose/number of inotropic drugs, blood transfusion and elevated WBC count postoperatively.

Effect of Therapeutic Hypothermia on Liver Enzymes in Patients With Stroke.

INTRODUCTION: A promising strategy that can lead to longer brain cell survival after an acute stroke is therapeutic hypothermia. It represents a controlled decrease in body temperature for therapeutic reasons. It is increasingly represented as a therapeutic option and is one of the most challenging treatments that improves neurological recovery and treatment outcome in patients with acute stroke. AIM: To examine the effect of therapeutic hypothermia on liver enzymes in patients with diagnosis of stroke. METHODS: A total of 101 patients diagnosed with acute stroke were treated. The first group (n=40) were treated with conventional treatment and therapeutic hypothermia, while the second group (n=61) only with conventional treatment. Cooling of the body to a target body temperature of 34°C to 35°C was performed for up to 24 hours. Outcome (survival or death) of treatment was monitored, degree of disability was determined by National Institutes of Health Stroke Scale (NIHSS) and assessment of consciousness using the Glasgow Coma Scale (GCS). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were taken at admission, after 24 hours, and were monitored upon discharge. RESULTS: There was a significant difference in AST values at admission relative to disease outcome (p = 0.002), as well as for ALT (p = 0.008). In patients treated with therapeutic hypothermia, mean AST values decreased after 24 hours (32.50 to 31.00 IU/mL) as well as ALT values (27.50 to 26.50 IU/mL), without statistical significance. In the group of subjects who survived with sequela, AST values correlated with GCS (rho = -0.489; p = 0.002) and NIHSS (rho = 0.492; p = 0.003), ALT values correlated with GCS (rho = -0.356; p = 0.03) but not with NIHSS. CONCLUSION: AST and ALT values at admission correlate with the severity of the clinical picture. Therapeutic hypothermia is hepatoprotective and lowers AST and ALT values.

From mechanical ventilation to intensive care medicine: a challenge for Bosnia and Herzegovina.

Intensive care medicine is a relatively new specialty, which was created in the 1950's, after invent of mechanical ventilation, which allowed caring for critically ill patients who otherwise would have died. First created for treating mechanically ventilated patients, ICUs extended their scope and care to all patients with life threatening conditions. Over the years, intensive care medicine developed further and became a truly multidisciplinary speciality, encompassing patients from various fields of medicine and involving specialists from a range of base specialties, with additional (subspecialty) training in intensive care medicine. In Bosnia and Herzegovina, the founding of the society of intensive care medicine in 2006, the introduction of non invasive ventilation in 2007, and opening of a multidisciplinary ICUs in Banja Luka and Sarajevo heralded a new age of intensive care medicine. The number of admissions, high severity scores and needs for mechanical ventilation during the first several months in the medical ICU in Banja Luka confirmed the need of these kinds of units in the country. In spite of still suboptimal personnel training, creation of ICUs in Bosnia and Herzegovina may serve as example for other developing countries in the region. However, in order to achieve modern ICU standards and follow European trends toward harmonisation of medicine, Bosnia and Herzegovina needs to take up this challenge by recognizing intensive care medicine as a distinctive specialty, by implementing a specific training program and by setting up multidisciplinary ICUs in acute care hospitals.

Spinal Column and Abdominal Muscles Loading in Pregnant Women Dependent on Working Postures.

INTRODUCTION: : Diastasis recti abdominis is consequence of mechanical forces that, proportionally to uterus and fetus augmentation, make pressure on anterior abdominal wall. Muscle tonus in pregnancy is significantly impaired. Stress relaxation of connective tissues and modified statics often cause back and leg pain. AIM: To evaluate whether pregnancy augment the spinal column and abdominal muscles loading and to what extent, based on anthropometric measurements and software analysis. METHODS: Twenty women participated in the study, having similar anthropometric measurements. Average height was 170 cm (mean), and weight 68.0 kg (mean). Three working postures were analyzed: upright (working posture 1), semi-bent (working posture 2) and bent (working posture 3) working postures by both non-pregnant and pregnant women. Simulation was made in software package CATIA. RESULTS: Analysis was done for working postures at workplace in pre-pregnancy period (height 170 cm, weight 68 kg) and during pregnancy (height 170 cm, weight 80 kg). From analysis of posture 2 and posture 3 in pregnant woman, conclusion can be drawn that despite of the fact that our examinees did not carry any external/additional loads, in these two working postures the abdominal muscles suffered overloading. CONCLUSION: It is crucial to strengthen the entire musculature for women who wish to get pregnant. The pre-pregnancy exercises might improve the posture, tonus and boost chances for safe labor and delivery. Strong abdominal muscles are needed to unload the spine. It is highly recommended to prepare their musculature for pregnancy through various pre-pregnancy exercises.

Application of EuroSCORE in "Heart center Sarajevo".

Our aim was to evaluate risk stratification model, European System for Cardiac Risk Evaluation (logistic EuroSCORE) for patients treated in clinical hospital. EuroSCORE is useful to separate patients into risk groups so that the mortality and morbidity risk can be compared. From 1st January 2006 to 31st July 2006 the total of 124 adults have been operated and were classified according to the EuroSCORE algorithm. We have compared correlation of the predicted mortality and observed mortality (as death within the 30 days following the operation) and frequency of postoperative complications. All patients were divided into three risk groups. The low risk group had 30 patients with 0 death (0%) and 1 morbidity (3,33%). The medium risk group had 59 patients with 0 death (0%) and 4 morbidity (6,77%). The high risk group had 35 patients with 2 death (5,71%) and 5 morbidity (14,28%). Mortality in our clinic is much less than predicted mortality and we can be satisfied with our results. Incidence of complications after cardiac surgery is between 25 and 40% (STS database). Our results are within that range. We recommend logistic version of EuroSCORE as good and simple method to predict postoperative prognosis.

Organism Encumbrance of Cardiac Surgeon During Surgery.

INTRODUCTION: Most everyday activities, performed over a long period leads to performance degradation of skeletal muscles as well as spinal column which is reflected in the reduction of maximum force, reduction of the speed of response, reducing control of the movement etc. Although until now many mathematical models of muscles are developed, very small number takes into account the fatigue, and those models that take into account changes in the characteristics of muscles for extended activities, generally considered tiring under certain conditions. Given that the current models of muscle fatigue under arbitrary conditions of activation and load are very limited, this article presents a new model that includes scale of muscles overload. MATERIAL AND METHODS: There are three female cardiac surgeons working performing these surgeries in operating rooms, and their average anthropometric measures for this population is: a) Weight: 62 kg; b) Height: 166 cm. Age: 45 taken in the calculation within the CATIA software, that entity is entitled to 50% of healthy female population that is able to execute these and similar jobs. During the surgery is investigated the two most common positions: position "1" and "2". We wish to emphasize that the experiment or surgical procedure lasted for two positions for five hours, with the position "1" lasted 0.5 hours, and position "2" lasted about 4.5 hours. The additional load arm during surgery is about 1.0 kg. RESULTS: The analysis was done in three positions: "Operating position 1", "Operating position 2 ', and each of these positions will be considered in its characteristic segments. These segments are: when the body takes the correct position, but is not yet burdened with external load, then when the surgeon receives the load and the third position when the load is lifted at the end of the position. Calculation of internal energy used on the joints is carried out in the context of software analysis of this model using CATIA R5v19. The proposed model is based on CATIA software model, which consists of visual indicators of the burden on certain parts of the body as well as the forces acting in these parts of the body. CONCLUSION: Based on these indicators to define which muscles, as well as that part of the skeletal system is overloaded, what is the position and what needs to be done that specific load be within permitted limits.

Extensive Operation as One of the Solution for Patients with the Insufficient Proximal Landing Zone for TEVAR in Aortic Dissection - short term results.

OBJECTIVE: In our study we wanted to showed the safety, feasibility, efficacy and way how to solve the problems of endovascular repair for aortic dissection with insufficient proximal Landing Zone. METHODS: The clinical data of all the patients with insufficient proximal Landing Zone (PLZ) for endovascular repair for aortic aneurism and dissection Stanford type B for the period from October 2013 to June 2014 was prospectively reviewed. According to the classification proposed by Mitchell et al, aortic Zone 0 was involved in 3 cases, Zone 1 in 1 case, Zone 2 in 9 cases and Zone 3 in 6 cases (19 patients in total). A hybrid surgical procedure of supraortic debranching and revascularization, with direct anastomosed truncus brachiocephalicus and left common carotid artery, were performed to obtain an adequate aortic PLZ. Revascularization of the left subclavian artery was carried out on the patient with dissection Stanford type B and short PLZ 2. RESULTS: There was no significant difference of risk factors between Zone 0, Zone 1, and Zone 2 (Table 1.), but the length of the PLZ significantly differed between groups (p<0.01) and there is no significant difference in technical and clinical success rate among the groups. CONCLUSION: The procedure of extending insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The TEVAR applicability in such aortic disorders could be extended.