MULTIDIMENSIONALITY AND MULTIDISCIPLINARITY OF CHRONIC NEUROPATHIC NONODONTOGENIC OROFACIAL PAIN.

This study compared the self-assessed health-related quality of life (HRQoL) and degree of depression between patients with chronic neuropathic nonodontogenic orofacial pain (NOFP) and healthy controls using the Short Form Survey (SF-36) health status questionnaire and Beck Depression Inventory II (BDI-II). This controlled cross-sectional study included 100 patients and 119 healthy controls. The diagnostic protocol recorded the following: 1) pain intensity using a visual analog scale for the time of examination and during the one-month prior; 2) evidence for neuropathic pain using the Leeds questionnaire for neuropathic signs and symptoms (LANSS); 3) emotional status using the BDI-II; and 4) HRQoL using the SF-36 questionnaire. The mean LANSS score was 17.18 in the patient group and 0.0 in the control group. The mean BDI-II score was 18.31 in the patient group and 5.87 in the control group. The SF-36 scores were shown with Mann-Whitney U testing to have statistically significant differences between the patient and healthy control groups in all categories. Vitality was the only SF-36 category in which the patient group scored higher than the control group. In conclusion, NOFP significantly reduces the self-reported HRQoL. NOFP is also related to the development of depression, but does not affect its severity. There is a significant correlation between depression and low quality of life in patients with NOFP.

AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.

PREOPERATIVE SINGLE ANTHROPOMETRIC SCREENING TESTS OF DIFFICULT FACE MASK VENTILATION AND DIFFICULT DIRECT LARYNGOSCOPY INTUBATION IN PATIENTS UNDERGOING OTORHINOLARYNGOLOGICAL SURGERY: A PROSPECTIVE, OBSERVATIONAL, SINGLE CENTER STUDY.

The aim of this study was to assess preoperative airway history data and single anthropometric screening tests of difficult face mask ventilation (FMV) and difficult direct laryngoscopy intubation (DLI) in otorhinolaryngological surgery. Final analysis included 62 patients aged ≥14 years undergoing elective surgery with endotracheal intubation at a single center during a one-month period. Data on difficult intubation history, airway symptoms and pathology related to difficult airway were prospectively collected. Han scoring classification of FMV and Intubation Difficulty Score (IDS) were used. There were 14 (22.6%) patients with a history of current airway tumors or abscesses. Only two (3.2%) patients were preoperatively evaluated as anticipated difficult airway. Both were slightly difficult to ventilate and scored IDS 5 and IDS 8. FMV was graded as easy in 50 (80.5%), slightly difficult in 10 (16.1%) and difficult in 2 (3.2%) cases. There were 29 (46.78%) slightly difficult DLIs and one (1.6%) case of difficult DLI. The study confirmed clinically relevant incidence of difficulties with FMV and DLI in otorhinolaryngologic surgery patients. However, there should be stronger evidence to identify a single preoperative variable predicting difficult airway.

WHOLE RANGE OF RESPIRATORY SUPPORT IN A PREGNANT WOMAN WITH A SEVERE FORM OF COVID-19 INFECTION: A CASE REPORT.

Acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) in pregnant women can progress to a critical condition. In this paper, we present a case of a woman in the 28th week of gestation hospitalized due to respiratory insufficiency caused by COVID-19 infection and consequent bilateral pneumonia with development of severe acute respiratory distress syndrome. Noninvasive ventilation through a face mask was started but due to progression of respiratory insufficiency with high FiO2 and positive end expiratory pressure (PEEP), we decided to intubate the patient, after which obstetricians agreed to complete pregnancy by cesarean section. The clinical course was complicated by desaturation and bradycardia with recurring asystole which recovered after the use of atropine. The patient was increasingly difficult to mechanically ventilate on the PSIMV modality (tidal volume [TV] <200 mL). She was switched to ASV modality (TV up to a maximum of 350 mL, ASV 130%, PEEP 16 cm H2O, FiO2 100%, RR 25/min, pPeak 35 cm H2O, pPlateau 35 cm H2O), after which peripheral saturation recovered to 89%. Due to inadequate mechanical ventilation, the patient was transferred to Dr. Fran Mihaljevic University Hospital for Infectious Diseases in order to perform extracorporeal membrane oxygenation (ECMO). Owing to all of the measures taken, recovery followed after 13 days on ECMO.

Mothers' Anxiety to Aggravated Acute Fear of Earthquakes in the City of Zagreb in the COVID-19 Pandemic.

BACKGROUND: Here we present the results of a psychometric investigation on current fear of COVID-19 infection aggravated by the earthquake-induced stress in the group of puerperal women. SUBJECTS AND METHODS: A group of 16 hospitalized puerperal women that gave birth at Clinical Hospital Sveti Duh in Zagreb, Department of Obstetrics and Gynecology were enrolled in retrospective clinical investigation. All the patients delivered during COVID-19 pandemic and experienced devastating earthquake on March 22nd. The women were interviewed on the exact day of the earthquake, 4 hours after the main hit and 6 months after that during second pandemic wave on October of the same year. Women were also questioned about the breastfeeding. The participants provided written informed consent and were interviewed using Generalized Anxiety Disorder 7-item (GAD-7) scale for evaluation of generalized anxiety disorder. RESULTS: Minimal level of anxiety after the earthquake was shown for 10 mothers with 6 of them having the highest level 4. Mild anxiety was proven for 3 patients, 2 exhibited moderate anxiety with one puerperal women with severe anxiety. One could say that 37.5% of enrolled patients exhibited some degree of anxiety after the earthquake (scoring >5). At second time point during COVID-19 pandemic 13 participants had minimal anxiety score, 2 had mild, while 1 participant had moderate score evaluated by GAD-7 scale (18.8%). At the time of the earthquake 13 participants were breastfeeding (81.3%), while 3 were not due to the personal reasons. 6 months after the earthquake only 7 mothers were breastfeeding (43.8%), while 9 of the participants were feeding their children with adapted milk (56%). Main reason for breastfeeding discontinuation was the stop of milk secretion in the 6 months period after the delivery. CONCLUSIONS: To our knowledge, our study is the only national study dealing with mental health problems in a population of puerperal and breastfeeding mothers in a challenging time of COVID-19 pandemic aggravated by devastating earthquake.

Perimortem Cesarean Section in a Patient with Intrapartum Cardiorespiratory Arrest Due to a Massive Amniotic Fluid Embolism.

We report and discuss the case of a 29-year-old tercigravida with intrapartum cardiorespiratory arrest due to a massive amniotic fluid embolism and disseminated intravascular coagulopathy. Perimortem caesarean section with B-Lynch compression uterine suture with simultaneous fetal and maternal resuscitation were performed with a favorable outcome for both the mother and the child.

CONVERSION RATE OF EPIDURAL ANALGESIA TO CAESAREAN SECTION REGIONAL OR GENERAL ANESTHESIA.

Introduction: Epidural analgesia is acknowledged as the most common method of analgesia during labor. If emergent Caesarean section (CS) is indicated in parturient with existing labor epidural, the need for conversion from epidural analgesia to regional (RA) or general anesthesia (GA) increases accordingly. Recent guidelines suggest the rate of conversion to general anesthesia shows the quality of obstetric anesthesia care and should be under 5%. The aim: The aim of this study is to determine the conversion rate from epidural analgesia to Caesarean section anesthesia in "Sveti Duh" University Hospital Zagreb in order to enhance the quality of anesthetic care for obstetric patients. Methods: We retrospectively included in the study all parturients who received epidural labor analgesia but needed subsequent regional or general anesthesia for Caesarean section in our institution for the period of 1st January 2021 to 31st December 2021. After the data analysis on the conversion rate from epidural analgesia to Caesarean section anesthesia had been performed, we compared our data to current standards and relevant literature findings. Results: Altogether 1202 epidural catheters were placed for labor analgesia in the study period, and in 199 of these cases, the emergent Caesarean section was indicated. Epidural analgesia was converted to epidural anesthesia (EA) in 153 (76,9%) parturients, to general anesthesia in 40 (20,1%), and to spinal anesthesia (SA) in six (3%) parturients. After comparison with recommended quality standards and with the results of similar studies by other authors, our findings show a significantly higher rate of conversion from epidural analgesia to general anesthesia than has been desirable since then. Conclusion: In order to reach the required quality standards regarding the conversion rate from epidural analgesia to Caesarean section anesthesia, it is necessary to improve the organization of the work of the obstetric anesthesiology team according to the principle of subspecialization. It is imperative to implement the best clinical practice protocols for obstetric anesthesiologists, but also to enhance the communication and coordination with the obstetric team.

HEMODYNAMIC FUNCTION IN COMPARISON OF TWO TYPES OF LOCAL ANESTHESIA WITH VASOCONSTRICTOR IN DAY SURGERY: RETROSPECTIVE STUDY.

Introduction: Hemodynamic changes and cardiac arrhythmias are not uncommon in clinical practice, depending on including patient features, surgical treatment and drugs administered. We describe hemodynamic changes developed in young patients, soon after a local infiltration anesthesia in day surgery. Methods: We retrospectively assessed the hemodynamic effect of 2% lidocaine with 0,0125mg/ml adrenaline (Li & AD) administered for septorhinoplasty in 44 participants and combination of 0.5% bupivacaine and 2% lidocaine with 0.0125mg/ml adrenaline (BLi & AD) for breast augmentation in 48 participants. Blood pressure and heart rate were recorded before the introduction of general anesthesia, immediately 5.10 and 20 minutes after administration of local infiltration, anesthetic (LIA) and data were analyzed. Results: The mean systolic blood pressure (SBP) in all observed measurements before general anesthesia (0), immediately, 5 minutes, 10 minutes and 20 minutes after local infiltration anesthesia was higher among patients who underwent septorinoplasty (Li & AD), in relation to patients who underwent breast augmentation (BLi & AD) (p <05). The level of diastolic blood pressure (DBP) in measurement 20 minutes compared to measurement in 10 minutes was increased by 9,52 mmHg. The septorhinoplasty group showed a significant increase in heart rate measured 20 minutes after local infiltration anesthesia with adrenaline. Conclusions: Measured transitory changes in heart rate and blood pressure after local infiltration of vasoconstrictor anesthetics in healthy patients prior to septorinoplasty and breast augmentation may be induced by endogenous and / or exogenous epinephrine. Bupivacaine solution for local infiltration analgesia reduces hemodynamic disturbances and prolongs analgesic effect. We highlight the need for careful preoperative evaluation, including anxiety assessment and treatment in all patients in day surgery.

TEN-YEAR FOLLOW-UP OF QUALITY IN REGIONAL ANESTHESIA AND ANALGESIA IN OBSTETRICS OBSTETRIC REGIONAL ANESTHESIA: IMPROVING QUALITY.

Introduction: Quality assessment of provided healthcare is becoming a standard in numerous health institutions worldwide, which is beneficial for both the patient and the institution. In order to achieve this standard, it is necessary to develop quality indicators in all segments of healthcare. Postdural puncture headache is a common complication following neuraxial blocks, especially in obstetric anesthesia. If severe, it is a cause of emotional and psychological distress and must be treated by a blood patch. Aim: The aim of this study was to determine whether the number of these complications is reduced when blood patch frequency is monitored and analyzed and to assess the effect of countermeasures in order to improve the quality and safety of regional anesthesia in obstetrics. Methods: Before 2009 and during that year at the University Hospital Sveti Duh, there had been a large number of severe postdural puncture headaches after spinal anesthesia and epidural analgesia treated by a blood patch in 6.12% of cases. After noticing the rising number of blood patches, we decided to analyses data every year. We recorded all blood patches injected to obstetric patients within the period of nine year, from 2009 to 2018 and concurrently we introduced a set of measures to improve the quality of neuraxial blocks, such as the use of atraumatic 26 or 27-gauge pencil-point spinal needles and modern neuraxial blockade protocols. Data were collected from anesthesiology and gynecology protocols and analyzed with MedCalc software, version 18.1.2. Results: The frequency of blood patch applications has been reduced from 6.12% to 0.30%, which is statistically significant. The percentage of placed epidural catheters for vaginal birth increased from 21% in 2009 to 38% in 2018. Although not statistically significant, the number of pregnant women undergoing a caesarean section is also growing, while the total number of births is falling. The proportion of cesarean sections in spinal anesthesia varies from year to year. Discussion: A statistically significant decrease in the number of installed blood patches clearly indicates the positive effect of measures taken to improve quality, which could contribute to the growing interest of pregnant women in childbirth in epidural analgesia. The number of placed epidural catheters is increasing despite the decline in the total number of deliveries and the increase in the number of deliveries completed by cesarean section. Conclusion: Monitoring the incidence of severe post-puncture headaches treated with blood patches has shown great progress in improving the quality and safety of regional anesthesia and analgesia in our institution, so we believe that monitoring the number of blood patches could serve as an indicator of regional anesthesia and analgesia in obstetrics. Monitoring the number of blood patches shows that the frequency of post-puncture headaches does not correlate only with the type of needle or epidural catheter used for neuroaxial blocks, but is also a sensitive indicator of any deviations from the achieved standards. Furthermore, it indicates the need for careful analysis of causes in order to adopt and implement appropriate countermeasures.

SPINAL ANAESTHESIA-INDUCED HYPOTENSION IN OBSTETRICS: PREVENTION AND THERAPY.

Regional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors.

MEDICO-LEGAL RESPONSIBILITY IN MANAGEMENT OF ACUTE AND CHRONIC PAIN IN OBSTETRIC.

Medico-legal responsibility in the management of acute or chronic pain in broad sense implies acting by the rules of good clinical practice and reducing the potential treatment side effects and complications that may entail health impairment and possible legal proceedings. Patients with acute or chronic obstetric or nonobstetric pain should be informed on the mode and method of treatment, possible side effects, and effects of drugs or procedures on fetal growth and development (informed consent). The principles of perinatal pharmacology and toxicology should be respected, choosing the mode of treatment associated with the lowest rate of side effects and a minimally invasive procedure (Accordingly, medico-legal responsibility is a professional and deontological category that should be fostered and implemented in line with professional guidelines and safety for both patients and medical staff.).

How to Improve Patient Safety Culture in Croatian Hospitals?

Patient safety culture (PCS) has a crucial impact on the safety practices of healthcare delivery systems. The purpose of this study was to assess the state of PSC in Croatian hospitals and compare it with hospitals in the United States. The study was conducted in three public general hospitals in Croatia using the Croatian translation of the Hospital Survey of Patient Safety Culture (HSOPSC). A comparison of the results from Croatian and American hospitals was performed using a T-square test. We found statistically significant differences in all 12 PSC dimensions. Croatian responses were more positive in the two dimensions of Handoff s and Transitions and Overall Perceptions of Patient Safety. In the remaining ten dimensions, Croatian responses were less positive than in US hospitals, with the most prominent areas being Nonpunitive Response to Error, Frequency of Events Reported, Communication Openness, Teamwork within Units, Feedback & Communication about Error, Management Support for Patient Safety, and Staffing. Our findings show that PSC is significantly lower in Croatian than in American hospitals, particularly in the areas of Nonpunitive Response to Error, Leadership, Teamwork, Communication Openness and Staffing. This suggests that a more comprehensive system for the improvement of patient safety within the framework of the Croatian healthcare system needs to be developed. Our findings also help confirm that HSOPSC is a useful and appropriate tool for the assessment of PSC. HSOPSC highlights the PSC components in need of improvement and should be considered for use in national and international benchmarking.

Development of a Croatian version of the US Hospital Survey on Patient Safety Culture questionnaire: dimensionality and psychometric properties.

BACKGROUND: The Hospital Survey on Patient Safety Culture (HSOPSC), originally developed in the USA, is used worldwide to assess patient safety culture in hospitals. A limited number of studies have provided data on psychometric properties outside of the US healthcare system. Our aim was to determine if all 12 dimensions of the US HSOPSC were applicable, valid and reliable to Croatian healthcare workers. METHODS: The study was conducted from September 2010 to April 2011. Questions were translated into Croatian and then translated back into English. The questionnaires (ie, the Croatian translation of the US HSOPSC) were distributed in unmarked envelopes along with a consent form to all the doctors and nurses in four Croatian hospitals. The responses were analysed using explorative factor analyses, reliability testing, and confirmatory factor analyses. RESULTS: The study included 561 healthcare workers in four Croatian hospitals--a response rate of 32.69%. Our results are similar to the original US sample, but with some differences: 11 dimensions with acceptable reliability scores were identified by exploratory factor analysis compared with the original 12 in the US sample; five of 12 dimensions had a Cronbach's α higher than 0.7, suggesting a reasonable fit to the original US HSOPSC; the dimensions 'Staffing' and 'Organisational learning--continuous improvement' were found to have a Cronbach's α <0.6. The use of confirmatory factor analysis confirmed a good fit to the original US model. CONCLUSIONS: Results show that the Croatian translation of the US HSOPSC is compatible in 11 of the original 12 dimensions. Results suggest that for the purposes of research in Croatia, the dimensions 'Staffing', 'Communication openness', and 'Organisational learning-continuous improvement' should be revised. For example, the use of question A7 ('We use more agency/temporary staff than is best for patient care') in the context of European healthcare systems should be adapted or removed for the Croatian version of the US HSOPSC questionnaire.

Analysis of the key issues in the organization of emergency care for stroke and heart attack patients in Bjelovar-Bilogora County.

Emergency care for patients with acute ischemic stroke and acute myocardial infarction according to the principles of evidence-based medicine is a challenge for the healthcare system, as it requires a multidisciplinary approach and good cooperation of all the subjects involved. The time elapsed from symptom onset to patient admission to the hospital, and the period from admission to the hospital to the beginning of therapy play an essential role in the thrombolytic treatment of stroke. For the patient, effective functioning of the system can mean the difference between preserved functional independence and disability. In recent years in Bjelovar-Bilogora County, there has been some development in emergency care of patients with acute heart attack by applying thrombolytic therapy and organizing transfer of indicated cases to the nearest clinical department for invasive cardiologic therapy. In case of acute ischemic stroke, thrombolysis has so far remained the only method of causal treatment. Results of a retrospective study conducted in 2010 in Bjelovar General Hospital on 169 patients with the established time of ischemic stroke symptom onset showed that only 39.64% of patients reached the hospital for treatment within the target time window. The results indicated the need for continuous efforts in preventing cardiovascular and cerebrovascular disease, as well as for education of citizens and healthcare professionals in recognizing the early symptoms of stroke and understanding them as an emergency condition. The present situation calls for permanent education of health workers in first line contact, an increase in the number of neurologists and cardiologists, as well as the introduction of stroke units on the model of coronary units, with constant presence of specialists. The radiology and laboratory services need adjustment to enable performing diagnostic procedures within the given time limit. At the national level, a network of stroke units should be organized, which would eliminate distance to county hospitals as a limiting factor in effective treatment.

[Medicolegal dilemmas on restraint use in delirious patients in intensive care unit]. / Medikolegalne dileme primjene ogranicavanja delirantnih bolesnika u jedinici intenzivnog lijecenja.

The use of physical or chemical restraint in delirious patients in the intensive care unit (ICU) is related to an array of ethical and medicolegal dilemmas. In most cases, they arise from insufficient knowledge of the regulations in force or due to their vague wording. The aim of this review article is to outline the basic views of the medical profession regarding restraint use as a method in the treatment of delirium and to give an insight into the existing legislation at the national and international level. According to the contemporary research, restraint of patients in delirium, whether it is physical restraint or application of psychoactive drugs, has a number of potentially harmful side effects and must be used with clear indications, under strict supervision, and with meticulously kept medical records. A delirious patient must be treated in accordance with medical ethics, international conventions and the laws and regulations related to patient rights. This includes the general principles of respecting the patient's autonomy and dignity, giving him or her timely information, notification of informed consent, as well as abiding by the rules of the profession integrated in every hospital written instructions on the treatment of a patient in delirium. A detailed medicolegal frame of restraint use in delirious patients is given by the Croatian Hospital Accreditation Rules, which is currently the highest existing standard for restraint use in delirious patients in ICU, as well as in the other hospital departments.

[Neurological disorders in pregnancy]. / Neuroloski poremecaji u trudnoci.

Preeclampsia is characterized by hypertension, peripheral edema and proteinuria, but very often also includes neurologic complications. Neurologic complications of severe preeclampsia are indentical to those of hypertensive encephalopathy. The most common neurologic symptoms are headache, vomiting, mental disorders, visual disturbances, sensorimotor deficits and seizures. Endothelial cell dysfunction is the main cause of multiorgan failure. It is of utmost importance to recognize these symptoms and initiate apropriate therapy. Systemic blood presure must not exceed the cerebrovascular autoregulatory capacity. Serum magnesium level is significantly decreased in pregnant women with severe preeclampsia and cerebral edema. Magnesium has been shown to be effective in reducing the occurrence of seizures in preeclampsia by decreasing neuronal excitability, protecting the endothelium against free radicals and reducing cerebral perfusion.

Lumboischialgia as the first sign of stomach cancer.

The paper reports on a case of a seventy-three-year-old male patient, whose disease was initially manifested by severe low back pain and lumboischialgia of the right leg as the first and only, and later, the leading symptom of disseminated adenocarcinoma of the stomach. The unusual presentation of stomach cancer confirms the necessity of simultaneous treatment of pain and determination of its etiology. It also indicates the need for re-evaluation of diagnosis when there is no favorable clinical effect of applied therapy.

Acute paroxysmal praecordial pain as a somatosensory elementary partial onset of epileptic seizure.

It presents a 60-year-old female patient with acute paroxysmal intensive pain attacks in the praecordial area that spread to the left hand and were associated with mild transient left hemiparesis, progressing to a myoclonic focal seizure in the region of left abdomen. The diagnostic procedure was interrupted several times by intensive pain attacks, but excluded acute thoracic pathological process, whilst a brain scan found a large, partially necrotic tumour with incipient bleeding and severe oedema subcortically in the right parietal lobe. We are describing a clinical presentation of symptomatic, simple focal, somatosensory epileptic seizure with dominance of intensive pain that progress in myoclonic, somatomotor focal seizure and Todd's Palsy as the first sign of glioblastoma bleeding.