Management of otogene extracranial complications in children and adolescents: report of 35 cases over 10 years.

OBJECTIVE: Medical management of exocranial otogenic complications represents a challenge for a medical system of a country in general, especially for ENT services. The goal of this study is to find some answers on demographic data, clinical symptoms and signs, diagnostics, and especially therapy for these complications in young patients. METHOD: The study is retrospective, performed in the ENT clinic of the University Clinical Center of Kosova in Prishtina and covers 10 years (from 01.06.2000 to 01.06.2010) and includes all young aged patients (1-18 years) hospitalized because of exocranial otogenic complications. RESULTS: From a total of 35 patients, male were 22 (63%) and females 13 (37%). The commonest complications were: mastoiditis in 18 (51.4%) and subperiosteal mastoidal abscess in 12 cases (34%) than rarest complications were: Bezold's abscess in 2 cases, facial nerve paresis, labyrinthitis, and combined complication one case each. Diagnostics of these cases were based on the clinical appearance, laboratory analyses, and clinical imaging. Treatment of these patients was surgical, medical, and combined: 3 of the medical therapy only (intravenous antibiotics), and 32 others were treated surgically: cortical mastoidectomy in 16 (45%) of cases, mastoidectomy and aeration tube insertion in 6 (17%) and antrotomy in 3 (8.5%) of cases. None of these series of patients died and none of them had permanent sequels. CONCLUSION: Timely diagnostics and adequate treatment of exocranial otogenic complications made it possible that our results can be comparable with the results of other referent centers cited in the recent literature.

Use of antibiotics in COVID-19 ICU patients.

INTRODUCTION: The role of antibiotics in the treatment in COVID-19 cases has not yet been adequately defined, and no criteria have been established for antibiotic treatment, type and duration. METHODOLOGY: This paper reports the results of an observational study on the extent of antibiotic use in 52 randomly selected patients in the intensive care unit (ICU) at the University Hospital in Pristina, Kosovo with severe forms of COVID-19. RESULTS: Antibiotics were prescribed in all the cases (52; 100%). Of the 52 patients, 1) 13 (25%) were given antibiotics before hospitalisation, 2) 49 (94.2%) during treatment in the ward and 3) 52 (100%) during treatment in the ICU. Most often, empirical antibiotics were administered in 32 cases (61.5%) to treat methicillin resistant Staphylococcus aureus (MRSA) infections, and in 23 patients (44.2%) to treat atypical pathogens. The most prescribed antibiotics were ceftriaxone/cefotaxime plus macrolide in (17 cases; 32.7%), ceftriaxone/cefotaxime in (15 cases; 28.8%), ampicillin/amoxicillin plus clavulanic acid or sulbactam (five cases; 9.6%), and quinolones (five cases; 9.6%). Imipenem was the most frequently used antibiotic in the ICU (30 cases; 57.7%), followed by ceftriaxone (28 cases; 53.8%), and piperacillin/tazobactam and fluoroquinolone (17 cases; 32.7%). In 18 cases (34.6%), three antibiotics were given simultaneously; two antibiotics in 29 cases (55.8%) and in five cases (9.6%) only one antibiotic was given. The mean duration of antibiotic treatment was 12.71 days (3-22 days; SD 4.026). CONCLUSIONS: The study showed unrestricted use of broad-spectrum antibiotics in the treatment of severe cases with COVID-19.

Smoking and COVID-19 in ICU Patients.

BACKGROUND: Case studies revealed an astonishingly low number of current among patients suffering from symptomatic COVID-19 compared to general population, leading to the conclusion that smoking/nicotine uptake might have a preventive effect. OBJECTIVE: This study aims to show the relation between smoking habits, present and past, and severity and outcome in COVID-19 patients hospitalized in the ICU of the University Hospital in Pristina. METHODS: This paper reports the results of possible association between smoking habits and severity and outcome of COVID-19. Data on smoking habits, present and past, among 73 patients with severe COVID-19 hospitalized at ICU are analysed and presented. RESULTS: Smokers (active and ex-smokers) in total were 16 (21.9%) cases (P<0.0001); active smokers were 5 (6.8%) cases (P<0.0001), ex-smokers 11 (15.1%) cases (P<0.0001), and non-smokers were 57 (78.1%) of the cases. From 16 cases (21.92%) identified as active smoker and ex-smoker, 8 of them ended with death, and other 8 cases survived; while 40 cases (54.79%) from the non-smoker group died, while 17 cases (23.29%) from this group survived (95% CI: 0.2881 to 1.5430, P=0.3792). Out of 5 (6.85%) cases of active smokers, 3 (4.11%) of them ended with death (95% CI: 0.1692 to 2.6846, P=0.855); while from 11 (15.07%) of ex-smokers, 5 (6.85%) died (95% CI: 0.1995 to 1.6412, P=0.3561). OR for death among smoker group of cases (active and ex-smokers) was 0.4250 (95% CI: 0.1370 to 1.3189, P=0.1386); for active smokers 0.2550 (95% CI: 0.0547 to 1.1892, p=0.0820), and 0.3542 (95% CI: 0.0950 to 1.3199, P=0.1220) for ex-smokers. Data on the influence of smoking on incidence and severity of COVID-19 ICU cases are conflicting. CONCLUSION: A protective effect of smoking in COVID-19 should not be inferred.

Acute Mastoiditis Complicated with Concomitant Bezold's Abscess and Lateral Sinus Thrombosis.

Bezold's abscess is a very rare extracranial complication of acute mastoiditis. Lateral sinus thrombosis is another intracranial complication of acute mastoiditis that can occur, but there are only few reports of concomitant ispilateral Bezold's abscess and lateral sinus thrombosis with favorable outcome. We diagnosed and treated successfully a 14-year-old girl suffering from Streptococcus pneumoniae acute mastoiditis complicated with Bezold's abscess and lateral sinus thrombosis. Surgical treatment included myringotomy, cortical mastoidectomy, and Bezold's abscess incision and drainage. During the course of treatment, we concluded that lateral sinus thrombosis was not caused from mastoiditis by direct spread but from pressure on internal jugular vein caused from Bezold's abscess.

Survey about the Extubation Practice among Anaesthesiologists in Kosovo.

BACKGROUND: Tracheal extubations may be performed before or after awakening from anaesthesia. The advantage of extubation during anaesthesia may avoid all the unpleasant effects of fully awake extubation such as severe hypertension and tachycardia, malignant dysrhythmias, myocardial ischemia laryngospasm, and cough induced high intraocular and intracranial pressure. AIM: To show the current practice of performing extubations in Kosovo, as well as the advantage and disadvantage in performing this procedure in an awake patient or inpatient in light anaesthesia. MATERIAL: This study is conducted at the Regional Hospitals and the University Clinical Center of Kosovo during the year 2015. A questionnaire is given to the anesthesiologists to collect information about the techniques used for extubation, timing and management of extubation. RESULTS: Based on this survey results that 86% of an anesthesiologist (71) extubate the patients when they are completely awake, while 14% of them (12) prefer to extubate the patients under light anaesthesia. From all anesthesiologists involved in this study, forty of them reported problems during extubation. Complications were related to airway, and they are treated by oxygenation and jaw support, but in rare cases, reintubation were performed. CONCLUSION: Complications during extubation remain important risk factor while extubation during light anaesthesia can minimise some of them.

From Pre-Existing Renal Failure to Perioperative Renal Protection: The Anesthesiologist's Dilemmas.

CONTEXT: Pre-existing renal dysfunction presents specific features that anesthesiologists must deal with. Anesthesia and renal function are connected and can interfere with each other. Induced hypotension anesthesia and the toxic effects of anesthetic drugs can further deteriorate renal function. EVIDENCE ACQUISITION: Decreased renal function can prolong anesthetic drug effects by decreased elimination of these drugs. Anesthesia can deteriorate renal function and decreased renal function can interfere with drug elimination leading to their prolonged effect. The anesthesiologist must understand all the physiological aspects of the patient, renal protection, and the relationships between anesthetic drugs and renal function. This review article aims to summarize these aspects. RESULTS: Perioperative renal failure and renal protection is a crucial moment in clinical practice of every anesthesiologist. CONCLUSIONS: Good knowledges for renal function remain a hallmark of daily practice of the anesthesiologist, considering renal function as an important determinant factor in anesthesia practice.

Anesthesia for trans-sternal thymectomy: modified non-muscle relaxant technique.

Anesthesia for thymectomy in myasthenia gravis is challenging. Early surgical management is now considered to be an important therapeutic intervention for most of the patients of myasthenia gravis. The anesthetic experience of that technique is quite large. It involves either muscle relaxant or non-muscle relaxant techniques. However, the literature is deficient of standard anesthetic technique for thymectomy. Therefore we present in this report a modified non-muscle relaxant technique for thymectomy. We report one case with thymectomy under general anesthesia using fentanyl and propofol for induction and endotracheal intubation using non-muscle relaxant technique. The intubating, intraoperative and postoperative conditions were excellent.

Comparison of epidural morphine versus intramuscular morphine for postoperative analgesia.

OBJECTIVE: To compare effects and side effects or complications of epidural versus intramuscularly administered morphine for relieve of postoperative pain. PATIENTS AND METHODS: In the first group (epidural) analgesia is achieved by application of morphine through epidural catheter. To the amount of morphine is added physiological solution until 10 ml of total volume of the mixture is achieved. This mixture is given to 150 patients, by epidural route before the exit from the operation room. Epidural catheter is removed after 48 hours. Second group (intramuscular) analgesia is realized by application of 10 mg of morphine by intramuscular route. Morphine is injected at the end of surgery. Pain is assessed with combination of verbal categorical scale and visual analog scale. Verbal categorical scale used is 8 points scale and contains words of Tursky: 0 no pain, 1 very low pain, 2 week pain, 3 mild pain, 4 moderate pain, 5 strong pain, 6 severe pain, 7 untolerated pain. Awareness is assed during first 24 hours. For this Reynolds 4 points scale is used: awaked 1, somnolent 2, sleepy 3, deep sleep 4. RESULTS: Pain assessed by visual analog scale (VAS) is 15.17-29.62 in the epidural group patients versus 26.39-70.83 in intramuscular group. Variation of respiration rate in both groups is not significant 22.21 +/- 4.23 and 23.98 +/- 2.72 in minute, in epidural and intramuscular morphine groups, respectively. PaCO2 and PaO2 values are similar without significant variation 35.34 +/- 4.72 mmHg in the epidural morphine group and 31.3 +/- 3.21 mmHg in intramuscular morphine group. CONCLUSION: Epidural administration of morphine provides better analgesia in quality, since it is deeper, longer in duration and with less inhibitory supra-spinal actions when compared to intramuscular administered morphine.

Emergence agitation in children after propofol versus halothane anesthesia.

BACKGROUND: The administration of anesthetic agents is associated with a high incidence of emergence agitation in children. Halothane and propofol appear to cause much less emergence agitation. The aim of this study was to compare the incidence of emergence agitation in children receiving either propofol or halothane anesthesia for a variety of surgical treatments using the Pediatric Anesthesia Emergence Delirium (PAED) scale. MATERIAL/METHODS: The subjects were 83 premedicated children aged 1 to 6 years who underwent surgical procedures with propofol (group P, n=41) or with halothane (group H, n=42) anesthesia. The mean dose during maintenance of anesthesia with propofol was 9.0 mg/kg/h or halothane 1.5-2% and fentanyl at a total dose of 5 microg/kg administered during surgery. Recovery time, preoperative anxiety, postoperative pain, and emergence agitation were noted. Adverse effects during and after operation were also recorded. RESULTS: Group P had a significantly higher proportion of patients who exhibited emergence agitation than group H (29.3% vs. 9.5%, respectively, P<0.05). The PAED scale score in group H was 4 (range: 0-16) and in group P 8 (range: 2-20). The mean recovery time in group P was significantly shorter than in group H (16.1+/-4.3 vs. 20.5+/-5.4 minutes, respectively, P<0.01). CONCLUSIONS: In children, the administration of propofol maintenance anesthesia is associated with a significantly higher incidence of emergence agitation than halothane maintenance anesthesia.