IS CARDIOPULMONARY RESUSCITATION OUTCOME IN PRE-HOSPITAL EMERGENCY MEDICINE RELATED TO AIRWAY MANAGEMENT TECHNIQUE?

According to current European Resuscitation Council guidelines, priorities in advanced life support in adult are chest compression with minimal interruption and early defibrillation. Endotracheal intubation is still considered the gold standard in airway management, but guidelines suggest that securing the airway be incremental, ranging from basic techniques to more complex ones. Doctors who work in pre-hospital emergency medicine teams (EMT) in Croatia usually lack sufficient education and expertise. The aim of this study was to determine whether there was a significant difference in recovery of spontaneous circulation during cardiopulmonary resuscitation (CPR) in out-of-hospital setting depending on the EMT airway management technique of choice. This retrospective analysis included data collected during a 10-year period at the Krapina-Zagorje County Emergency Medicine Institute on all patients with CPR performed by EMTs 20 minutes from initial emergency call. The airway management groups included oropharyngeal tube, i-gel supraglottic device, and endotracheal tube. There were 968 patients, mean age 70. In 74.61% of patients, the cause of arrest was of cardiac etiology. Our study did not find a statistically significant in difference of CPR success among the three groups analyzed according to the airway management technique of choice (p=0.74, χ2-test).

AIRWAY MANAGEMENT WITH RIGID BRONCHOSCOPE IN ADULT PATIENT DURING CERVICAL SPINE SURGERY: A CASE REPORT.

SCIWOCTET is a cervical spine injury (CSI) with objective signs of myelopathy, due to trauma, without evidence of ligament injury or bone fractures on x-ray and computed tomography (CT) images. It is rare, found in about 3% of patients with CSI. Perioperative manipulation of these patients may cause secondary spinal cord injury. The challenge for the anesthesiologist is to manage an airway with as little movement of the patient's head and neck as possible. A patient is presented after a fall from a motorbike. At hospital admission, he had neurological deficit in the innervation area of the cervical spinal cord. Multi-slice CT of the head and cervical spine was without signs of acute bone trauma. Magnetic resonance imaging was performed and the diagnosis met the criteria defining SCIWOCTET. Elective cervical spine surgery under general anesthesia was performed, the patient was intubated with a rigid bronchoscope using manual in-line immobilization. The selection of instruments and procedures is emphasized. Other procedures, techniques and instruments that can be used for airway management and their influence on the movement of the patient's head and neck are listed. It is concluded that rigid bronchoscopy with the application of manual in-line immobilization is suitable for emergency and elective intubation of patients with cervical spine pathology.

Who is the patient? Disclosure of information and consent in anesthesia and intensive care (informed consent).

Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the practice, however with the vast advances in science and technology, numerous ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hippocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together represent the complete best interest of the patient. This is the basic goal of the "Informed Consent". The widening of legal boundaries regarding professional liability may consequentially lead to a "defensive medicine" and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evaluating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief explain all the necessary information a "reasonable" anesthesiologist would disclose to a "reasonable" patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient.

Perioperative management with glucose solution and insulin.

The objective of this study was to analyze how preoperative glucose treatment influences the blood glucose level as a measured exponent of surgical stress and to establish the best postoperative replacement considering glucose solutions and insulin. This prospective clinical trial involved 208 non-diabetic patients with normal glucose tolerance, who underwent major surgical procedures and needed 24 hours ICU monitoring postoperatively. Patients were randomly given 5% glucose solution (1000 mL) one day before surgery or after overnight fasting. Group A and group B were randomized to be given 5 different kinds of postoperative replacement with cristalloids and insulin. None of the patients from group A or group B were given glucose solutions during surgical procedures. Blood glucose levels were measured 14 times from the preoperative period until 24 hours after admission to the ICU and the main outcome measure was blood glucose level. All patients had a statistically significant increase in blood glucose levels in comparison to basal levels (p < 0.05) in all measurements. All data were processed with descriptive statistics, chi-square test, parametric ANOVA test and ANOVA test with repeated measure, non parametric Kruskal-Wallis test and Mann-Whitney U-test. Statistically significant change was accepted with p < 0.05. Preoperative glucose infusion decreased metabolic and endocrine response only during surgery; the smallest increase of postoperative blood glucose level was noticed after administering postoperative non-glucose crystalloid solutions; there is no clinical evidence that one specific postoperative replacement is better than the other; there is no clinical evidence that postoperative use of insulin can decrease or attenuate surgical induced insulin resistance.